"*" indicates required fields

Welcome to Our Practice!

First Name*

Last Name*

Phone*

Address*

Street Address

Address Line 2

City

State

ZIP Code

Spouse/Partner Name

Spouse/Partner Phone

Your Primary Contact Numbers

Include contact information for person’s authorized to treat

Name

Phone

Type (cell, work, etc)

Cell

Work

Other

Name

Phone

Type (cell, work, etc)

Cell

Work

Other

Name

Phone

Type (cell, work, etc)

Cell

Work

Other

Who is authorized to treat your pet in your absence*

Primary e-mail address for communications*

We use email for Pet Portal access, newsletters, reminders, and client education. We never sell email addresses.

Your Driver's License Number/Name*

The State of Michigan requires us to report any controlled substances that we prescribe or administer to our patients, therefore we need your date of birth and driver’s license number on file.

DOB

MM slash DD slash YYYY

Your Employer*

Employer Phone*

Partner's Employer

Partner's Employer Phone

Patient Information

Pet's Name*

Breed*

DOB/Age*

Color*

Sex*

Male

Male Neutered

Female

Female Spayed

Last Exam Date*

Rabies Due Date*

Do you want to add a second pet?*

Yes

Second Pet Information

Pet's Name*

Breed*

DOB/Age*

Color*

Sex*

Male

Male Neutered

Female

Female Spayed

Last Exam Date*

Rabies Due Date*

Would you like to add a third pet?*

Yes

Third Pet Information

Pet's Name*

Breed*

DOB/Age*

Color*

Sex*

Male

Male Neutered

Female

Female Spayed

Last Exam Date*

Rabies Due Date*

Additional Information

Previous Veterinarian*

Phone*

Do we have a copy of your pets medical history?*

Yes

What is your pet taking for heartworm and flea/tick protection?*

Is your pet currently insured with a pet health insurance company?*

Does your pet or any members of your household have any allergies?*

* During your visit with us, we offer a wide variety of treats to your pet. this may include products containing nuts, wheat, or soy. Please let us know if there are any known allergies.

How did you first learn about our hospital? We would like to thank any individuals who referred you*

Hospital Sign

Facebook

Google

Website

Friend/Relative/Co-worker

Local Business

Other

Please check all that apply

Referred by*

Record Release

In the event that a request is made for your pet’s medical record to be released for any purpose, we would like your permission to release the record as follows

Records Release Consent*

I authorize the release of my pet’s medical records in any circumstance without contacting me

I do not authorize release of my pet’s medical records unless you get my verbal permission prior

I authorize the release of my pet’s medical records in an emergency situation only

Other – Please indicate how you would like us to handle your pet’s medical records if a request is made

Please only check one

Please Describe*

Photo Consent

Ottawa Animal Hospital and it’s representatives hold the right to photograph my pet(s) and to use & publish said photographs for any lawful purpose, including, for example, such purposes as education, publicity, advertising, and web content.

Photo Consent*

I authorize Ottawa Animal Hospital to photograph and publish photos of my pet

I do not authorize Ottawa Animal Hospital to photograph and publish photos of my pet

PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED

We accept cash, local checks, Visa, MasterCard, Discover, American Express, and Care Credit.

I agree to be responsible for authorizing procedures and/or paying for services. Any unpaid balance will accrue finance charges monthly and court fees if sent to collections

Signature*

Date*

MM slash DD slash YYYY

Statement of Ownership

I certify that I am the true owner and/or agent of the above animal(s) and have authorization to consent to treatment if and when it is needed. I understand that by signing this document, I agree to the above terms of service.

Signature*

Date*

MM slash DD slash YYYY

Name

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

New Client Form

Welcome to Our Practice!

Your Primary Contact Numbers

Patient Information

Second Pet Information

Third Pet Information

Additional Information

Record Release

Photo Consent