Owner(s) Name *

First

Last

Any Additional Authorized Guardians

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Home/Cell/Work

Who does it belong to?

Can it receive texts?

Email Address *

Preferred method of contact *

Phone
Email
Text Message

If you are new to our hospital, how did you become aware of us? *

Whom may we thank for your visit? *

Do you have pet insurance? *

Yes
No

What type?

May we use photos of your pet(s) on our website, Facebook and Instagram accounts? *

Yes
No

May we release your phone number, name and/or vaccine information to the Humane Society, County officials, or individuals that have identified your pet by a rabies vaccine tag or microchip and wish to contact you to return your pet? *

Yes
No

We accept: Cash & Check / Debit Card / MasterCard / VISA / Discover / American Express / CareCredit

Patient Information

Please fill out the following for your pet(s) under our care:

Patient Name *

Species (Choose one) *

Dog
Cat
Other

Other *

Breed *

Gender (Choose one) *

Male
Female
Neutered Male
Spayed Female

Color/Markings *

Known Allergies *

Important Medical Issues: *

Patient Name

Species (Choose one)

Dog
Cat
Other

Other *

Breed

Gender (Choose one)

Male
Female
Neutered Male
Spayed Female

Color/Markings

Known Allergies

Important Medical Issues:

Terms of Service

I assume full responsibility for all charges incurred and understand that a deposit may be required for hospitalization and/or treatment. I understand that Pine Meadow Veterinary Hospital does not extend credit out of the office, that ALL PROFESSIONAL FEES ARE DUE AT THE TIME OF SERVICES RENDERED, and I agree to pay for these services. I understand that there is a minimum $20.00 service charge on all returned checks. Any unpaid accounts will be subject to a monthly interest charge of 2% and, should my account be assigned for collection, I will be responsible for all court costs and attorney’s fee of thirty-three and one-third percent of all monies due. I hereby authorize Pine Meadow Veterinary Hospital and its staff to examine, prescribe for, and/or treat my pet(s). All information I have provided here is true to the best of my knowledge. I have read and understand the Terms of Service.

Signature of Owner or Financially Responsible Party

Clear Signature

(Must be 18 years or older)

Today’s Date *

Online Forms

New Client Form

New Client Form

Patient Information

Ready to Schedule an Appointment?

Hospital Address

Contact Information

Hours

Have a Question?