New Patient Form CLIENT INFORMATIONClient Name(Required) First Last Additional Name First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone:(Required)What type of number?(Required) Mobile Land Line Whose Number(Required)Alt Phone:What type of number? Mobile Land Line Whose NumberClient Email(Required) Have any of your pets been here in the past?(Required) Yes No If Yes, list pet namesREFERRING VETERINARIAN INFORMATIONDVM(Required)Hospital Name(Required)DVM/Hospital Phone Number(Required)PET INFORMATIONPatient Name(Required)Species(Required)Breed(Required)Color(Required)Age or DOB(Required)Weight (Kg)(Required)Sex(Required) Male Male Neutered Female Female Spayed Is your pet aggressive or fearful during veterinary visits? Yes No What is the primary medical concern for your pet?(Required)AuthorizationDo you consent for pictures of your pet and/or their procedure to be used in veterinary educational material, on-line social media, or our website?(Required) Yes No I hereby authorize Scissortail Veterinary Specialists to examine, prescribe for, and/or treat the above describedpet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these chargesmust be paid at the time of discharge and that a pre-payment will be required for all surgical procedures andtreatments.Accepted forms of payment include debit card, Mastercard, Visa, Discover, and Care Credit. Should this accountdefault and is referred to an attorney for collection, then I agree to pay all collection costs, including attorney fees upto 40% of the principal amount due and owing when turned over for collection. I also agree to pay interest on theunpaid balance at the rate of 1.5% per month (18% per annum) from the date that said monies become due andpayable. I authorize.Signature(Required)
