New Patient Form

NEW PATIENT FORM

Owner’s Name

Co-Owner’s Name

Mailing Address

City

State

Zip

Primary Phone

Cell Phone

Other

Preferred Method of contact? Home-Cell-Email-Text-Other

If email is preferred, how often do you check it?DailyWeeklyMonthlyOther

Best time to call about your pet?AMPMAny

Phone# to call

In an EMERGENCY, call

How did you hear about us?Internet Search (Google, Yahoo, etc)Social Media (Facebook, Twitter, Instagram)Personal ReferralOther

Please list Other name so we may thank them

Pet History

Pet’s Name

Date of Birth

Breed

Color

SexMaleMale NeuteredFemaleFemale Spayed

Is your pet MicrochippedYesNo

SpeciesDogCat

Previous Veterinarian(s) where past records could be obtained

Has you pet been treated for any illness in the past year?YesNo

Medications and dosage

I DODO NOTallow Akeso Veterinary Clinic to post pictures of myself, children, or my pet to any social media outlet.

By signing below, I give the Veterinarian at Akeso Veterinary Clinic authorization to treat my pet. I understand I am responsible for payment in full at the end of my visit. I also understand that by signing below, I authorize Akeso Veterinary Clinic to disclose the above-named animal’s medical records to be used by other emergency or referral veterinary practices, groomers, animal shelters or boarding kennels.

I agree I am responsible for any charges incurred by my pet and that payment is due at the time of service. We conveniently accept payment in the form of cash, check, credit card (Visa, MasterCard, American Express, and Discover) and offer payment plans (with pre-approval) through Scratchpay and CareCredit.

Signature of Responsible Party (Must be 18 years or older)