New Patient FormNew Patient Form Owner InformationOwner’s First NameOwner's Last NameNew Patient’s Information SpeciesDogCatOther Pet's Name Pet's Breed Pet's Color Pet's Birthday Pet's Sex Female IntactFemale SpayedMale IntactMale Neutered Has your pet been spayed and neutered?YesNo Has your pet had an adverse reaction to medications or previously given vaccines?YesNo [group group-28 clear_on_hide] If yes, which medication or vaccines and what happened?[/group]Who may we contact for pet's previous veterinary records? (Please include name & phone # if applicable) Does your pet have insurance?YesNo[group group-271 clear_on_hide] If yes, Policy Number and Name [/group] Has there been any recent changes to your home address, phone #, email, or other personal information?YesNo[group group-272 clear_on_hide] If yes, please list any changes [/group]**Please note our software is only integrated with Trupanion and therefore only submit their claims ** Social Media Release I hereby authorize the use of photos and/or videos related to my pet’s experience at Rockaway Animal Hospital. I understand my pet may be used in publications, posts, videos or stories on our social media platforms. My consent is freely given as public service without expecting payment. I release this establishment and their respective employees from any and all liability which may arise from the use of videos and or photographic images.YesGuarantor Form As the owner/ co owner of my pet (s) account I understand and acknowledge that full payment is due at the time of service, pick up ,drop off or purchase of products for my pets accounts(initial) As the owner/ co owner of my pet (s) account I understand and acknowledge that Rockaway Animal Hospital doesn't offer in-house payment options, if I am in need of a payment solution I should use Icare, Care Credit or Scratchpay(initial) As the owner/co owner of my pet (s) account I understand and acknowledge that estimates are only provided if requested and it is my responsibility to ask for a written estimate prior to my pet (s) exam if needed(initial) As the owner/co owner of my pet (s) account I understand and acknowledge that I am responsible to submit my pet (s) insurance claim(s) and pay upfront for the visit regardless if claim is approved or denied(initial) Signature Date download pdf
