~Welcome to Lost Mountain Animal Hospital~

~New Patient Form~

 

Please complete the following information so that we may begin a medical record for your pet.  

                                                                                         

Today’s Date _______________________________

 

Owner’s First Name__________________________ Last Name_______________________________________

 

Address___________________________________ City_____________________________________________

 

State______________________________________ Zip Code________________________________________

 

Home Phone_______________________________ Cell Phone_______________________________________

 

Place of Employment _____________________________________ Work Number_______________________

 

Driver’s License # _____________________________ State ________________  DOB ___________________

 

SSN ___________________________________ (If you plan on paying by check, we will need these numbers)

 

Spouse’s Name _________________________________ Cell Phone _________________________________

 

Place of Employment _______________________________________Work Number_____________________

 

Pet’s Name________________________________________________DOB_____________________________

 

Breed____________________________________Color_________________________ Sex:  Male   /   Female

 

Is the pet?      Spayed (F)   or   Neutered (M)      Is your pet current on vaccinations?___________________

 

If so, what animal hospital/clinic?_______________________________________________________________

 

Please tell us how you heard about us?__________________________________________________________

 

If it’s a friend, what is their name? _________________________________________ (For our rewards program)

 

E-mail address: _____________________________________________________________________________

 

Please read the paragraph below and sign:

 

I understand that payment is required at the time that services are rendered and that any deviation from this procedure must be discussed in advance of treatment. I also authorize any doctor employed by Lost Mountain Animal Hospital to treat my pet(s) as agreed upon when examined. I understand that situations may arise during anesthesia, hospitalization, or boarding which may require immediate medical or surgical attention. I request that an attempt be made to contact me should the need arise, but I authorize the attending physician to proceed as needed for the most successful outcome.  I have read and understand the above and agree. I am over the age of 18 years, I am the legal owner or authorized representative for the above pet.  

                        

Owner’s Signature:__________________________________________________