New Patient Form

Name*

First Last

Occupation

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Co-Owner

First Last

Occupation

Phone

Please list any Petsitters or other individuals who will be authorized to pick up your pet:

Please list each pet:*

Name	Species	Breed	DOB	Color	Pet Gender	Altered?	Microchip #

Videos and pictures are routinely taken during treatments and evaluations in order to assess the patients progress. These pictures and videos will become part of the pet’s permanent medical record. Please read the statements below and choose those statements for which you give consent.*

I authorize the use of my pet’s videos and or pictures for educational purposes (professional presentations by Dr. Pittman)
I authorize the use of my pet’s videos and or pictures for promotional use on the practices website.
I authorize the use of my pet’s videos and or pictures on the practices Facebook page.
Please do not use my pets videos and or pictures for anything other than to supplement the medical record.

I authorize the release of my pets medical records to Animal Wellness & Rehabilitation Center

I authorize the release of my pets medical records to Animal Wellness & Rehabilitation Center
I authorize Animal Wellness & Rehabilitation Center to release my pet's records to other Veterinary facilities, boarding facilities or Insurance companies.

Please list Primary Care/Previous Veterinary Hospitals with phone numbers.

Primary Care/Previous Veterinary Hospital	Phone Number

Do you have Pet Insurance?*

Yes
No

Please provide the Insurance Company and Policy Number.*

Insurance Company	Policy Number.

How did you hear about us? Whom we may thank?

Signature*

Full Name

Date*

Name

This field is for validation purposes and should be left unchanged.