New Patient Form

Pet's Name *:

Previous Veterinarian:

Allergies / Medical Conditions:

Species:

Breed:

Color:

Sex:

Spayed / Neutered:

DOB:

If your pet is a dog

Diet:

Flea Control Method:

Heartworm Prevention Type:

If your pet is a cat

Diet:

Flea Control Method:

Indoor / Outdoor:

Declawed?:YesNo

If so, # of feet:

Felv Status:

Test Date:

FIV Status:

Test Date:

Owner's Name:

Date:

Spouse / Secondary Owner:

Address:

City:

State:

Zip:

Mailing Address (if different from above):

Home Phone:

Cell Phone:

Email Address:

Would you like for us to occasionally email you updates, reminders, etc?YesNo

Owner's Information

Employer:

Work Phone:

Emergency Contact Name:

Phone:

Referral

Circle One

InternetVet ConnectSignYellow Pages

Person (by whom):

Other (please be specific):

I hereby authorize the veterinarian to examine, prescribe for, and/or treat the above described pet. I assume full responsibility for all charges incurred for the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment. (SEAL)

Do we have permission to use your pet's picture on our website and social media?YesNo

SIGNATURE OF OWNER

Select form of payment: CashPersonal Check (with license number)Care CreditDiscoverVisaMastercardAmerican Express

Eastwaye Veterinary Clinic is a full-service animal hospital whose mission is to provide the highest standard of veterinary care for pets. We genuinely care about your pets and all animals! Our staff is passionate about veterinary medicine and are extremely well trained. We strive to provide professional, affordable, and advanced veterinary services. At our clinic, you will walk into a calm, welcoming, and friendly environment every visit, so that the experience is as comfortable as possible for you and your pet.