New Client/Patient Form – Braelinn Animal Hospital

Name

First Last

Spouse/Other

First Last

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Email

Enter Email Confirm Email

Place of Employment:

Work Phone

Spouse's Place of Employment:

Work Phone

In case of emergency, please call:

Phone

Referrals are the greatest compliment our hospital can receive. We would like to acknowledge and thank those who refer new clients to us. Please help us do so by telling us how you heard about our hospital:

Please help us acknowledge and thank the individual that referred you:

Please help us acknowledge and thank the organization that referred you:

*** Due to state law and insurance requirements, ALL patients MUST be current on his/her Rabies Vaccine. Vaccinations will be updated at the time of hospitalization or boarding if they are not current.

*** To help prevent the spread of infectious disease, ALL hospitalized and boarded pets must be current on all required vaccines and free of both internal and external parasites.

Braelinn Animal Hospital will occasionally record photos, video, and audio to publish on various media sites for the purpose of education, marketing, and publicity. Please check in this box below if you authorize Braelinn Animal Hospital to record, own, publish, and republish information about me/ my pet(s) and reproductions of my likeness and my voice. By checking the box below, you are also indicating that you are 18 years of age or older.

I release Braelinn Animal Hospital from any and all claims that might arise from the use of these images and recordings

Name*

First Last

Date*

Pet #1

Name:

Sex:

Spayed Female
Intact Female
Neutered Male
Intact Male

Breed:

Birthday/Age:

Color/Description:

Date of Last Vaccines:

Hospital Where Given:

Prior Illnesses/Surgeries:

Do You Consider Your Pet Part of Your Family?

Reason for Today’s Visit:

Do we have your permission to request a transfer of records?

Would you like to input information for a second pet?

Yes
No

Pet #2

Name:

Sex:

Spayed Female
Intact Female
Neutered Male
Intact Male

Breed:

Birthday/Age:

Color/Description:

Date of Last Vaccines:

Hospital Where Given:

Prior Illnesses/Surgeries:

Do You Consider Your Pet Part of Your Family?

Reason for Today’s Visit:

Do we have your permission to request a transfer of records?

New Client/Patient Information

Pet #1

Pet #2

**If you have additional pets and would like to fill out information for them at this time, please let one of our staff members know. Thank You.

Contact Us

Our Location

Emergency

Our Hours