ORION - New Client/Patient Intake Form

New Client/Patient Intake Form
Client Name*
Client Email*
example@example.com
Patient Profile
Name*
Breed*
Weight*
D.O.B*

MonthDayYear
Date
Type
Sex*

MaleFemaleNeuteredSpayed
Welcome to our veterinary clinic and thank you for giving us the opportunity to care for your pet. We look forward to working with you in maintaining your pet's health. So that we may become better acquainted with you and your pet, please complete the following:
OWNER INFORMATION
Owner Full Name *

First NameLast Name
Secondary on account
Full Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
I would like to receive emails about upcoming events, special discounts, and hospital changes*

YesNo
I authorize Orion Animal Care Center to use photos of my pet on marketing and social media posts.*

YesNo
AUTHORIZATION/PAYMENT POLICY
Payment is due when services are completed or when patient is released. If you have any questions regarding fees, we will be happy to discuss them with you at any time. We accept Visa, Master Card, Discover, American Express, Care Credit and personal checks and cash payments. Please note there is a $25 charge if your check is returned by the bank. I assume responsibility for all charges incurred in the care of my pet.*

I acknowledge and agree to the payment policy
I, the undersigned owner or agent of the owner, certify that I am 18 years of age or older, and do hereby authorize Orion Animal Care Center veterinarians and technicians to examine my pet(s) named above and administer treatment as is considered necessary for my pet's condition.
Owner Signature*

Clear
Date*

MonthDayYear
Date
PET INFORMATION
Pet's Name*
Pet Type*

DogCatOther
Breed
Gender*

MaleFemale
Is your pet spayed/neutered?*

YesNo
Color*
Date of Birth

MonthDayYear
Date
Approximate Age (if birth date unknown
Previous Medical Records at (hospital name)
Should be Empty:

New Client/Patient Intake Form

Patient Profile

OWNER INFORMATION

AUTHORIZATION/PAYMENT POLICY

PET INFORMATION