Pine Hollow Veterinary Services Northwest PA & Northeast OH

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aacinfo@pinehollowvet.com

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Albion Animal Clinic: Where Our Passion is Paved with Paw Prints

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Our Forms

NEW CLIENT REGISTRATION FORM
PET MEDICAL HISTORY FORM

New Client Registration Form

Have you been to our clinic before?

Yes

No

If so, when and under what name?

I was referred to the clinic by:

Your Name:

Free Text

Your Address:

Your address:

City

State

Zip Code

Home Phone:

Cell Phone:

Work Phone:

Date of Birth:

Email:

Free Text

SECONDARY NAMES ON ACCOUNT

Are there any other names that need to be added to this account that are authorized in the treatment decision making process and will provide financial responsibility?

Yes

No

Secondary Name on Account:

Secondary Address:

Secondary Phone:

This individual is over 18 years of age.

Yes

No

Free Text

PATIENT INFORMATION - FOR ADDITIONAL HOUSEHOLD PETS

Pet Name:

Pet Sex:

Breed:

DOB or Age:

Color:

Free Text

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Pet Name:

Pet Sex:

DOB or Age:

Breed:

Color:

Free Text

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Pet Name:

Pet Sex

Breed:

DOB or Age:

Color

Previous Veterinarian where past records may be obtained if necessary:

I consent the release of my pet's medical information to Albion Animal Center.

I prefer pet health reminders be sent by:

E-mail

Postcard

Both

Free Text

STATEMENT OF GOODWILL

I am 18 years of age or older and take on the financial responsibility of the care of this animal or any animal that is listed under my account at Albion Animal Center.

I assume responsibility for all charges incurred in the care of this pet(s) that I have treated at Albion Animal Center. I hereby authorize treatment as considered necessary. I also understand that these charges will be paid in full at the time of service.

I understand that payment is due at the time of service and that accepted forms of payment are: Cash, Check, Money Order, Care Credit, Scratchpay, Visa, Mastercard & Discover. I also understand that checks will not be held or post dated for payments.

A copy of my driver’s license has been given for identity purposes & if I write a check.

My driver's license # is:

My driver's license expires on:

I understand that me or my pet(s) may be photographed or filmed while at the premise and I give permission to the clinic and all their affiliates to use any and all photos, video footage, written material and/or video streaming for promotional, sales, publicity and advertising purposes for all media including the internet.

Yes

No

Initial

Typing my name below indicates my signature stating that I agree with all initialed items in this document.

Date:

Thank you for completing and submitting our NEW CLIENT REGISTRATION FORM. We will contact you if we have any questions. Please also fill out the PET MEDICAL HISTORY FORM.

The Staff at Albion Animal Center

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PET MEDICAL HISTORY FORM

Owner Name:

Street Address:

City:

State:

Zip Code:

Phone:

Email:

Free Text

SCHEDULED APPOINTMENT INFORMATION

1) Appointment Date:

2) Appointment Time:

3) Reason for appointment:

Free Text

PATIENT INFORMATION

4) Pet Name:

5) Type of Pet:

Other

6) Your pet is...

Indoors

Outdoors

Both

7) How many pets are in your household?

1

2

3-5

6+

8) Brand of Pet Food

9) Type of Pet Food:

Canned

Dry

Both

10) How is your pet's appetite?

Normal

Other

Other

11) How is your pet's attitude?

12) Is your pet drinking?

Normally

More than normal

Less than normal

13) Do you notice any of the following? (Check all that apply.)

Limping

Eye Discharge

Nasal Discharge

Lumps

Sneezing

Coughing

Shaking Head

Scooting

Vomiting

Diarrea

Chronic Bad Breath

Weight Loss

Lethargy/Weakness

Seizure

Hair Loss

Pain

Drooling

Excessive Urination

Incontinence

Free Text

PATIENT MEDICAL HISTORY

14) Previous Veterinary Hospital

15) May we request your records from that office?

16) Has your pet had a physical examination in the last 12 months?

17) Has your pet had a dental examination & cleaning?

18) Has your pet had a Heartworm Test?

19) Has your pet had a Lyme Test?

20) Has your pet had a fecal test?

21) Has your pet had blood testing for kidney & liver function

22) Has your pet been vaccinated for Rabies in the past 12 months?

23) Has your pet been vaccinated for Canine Distemper in the past 12 months?

24) Has your pet been vaccinated for Lyme Disease in the past 12 months?

25) Has your pet been vaccinated for Kennel Cough in the past 12 months?

26) Has your pet been vaccinated for Feline Distemper in the last 12 months?

27) Has your pet been vaccinated for Leukemia Disease in the last 12 months?

28) Has your pet been dewormed in the past 6 months?

29) Has you pet received Flea & Tick preventative?

30) Has your pet received Heartworm preventative

31) Current medications & allergies:

Comments:

Thank you for completing and submitting our PET MEDICAL HISTORY FORM. We will contact you if we have any questions.

The Staff at Albion Animal Center

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©2017-23 Pine Hollow Veterinary Services

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New Client Form

Pet Medical History Form

Address: 11 Wells Ave, Albion, PA 16401

Email: aacinfo@pinehollowvet.com

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