New Patient Registration & Drop Off Form Owner's Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Primary Phone Number * (###) ### #### Secondary Phone Number (###) ### #### Secondary Contact Name Pet's Name * Species * Canine Feline Breed * Description * Colors, Distinctive Markings, etc. Date of Birth * If you are not sure, please estimate. MM DD YYYY Sex Male Intact Male Neutered Female Intact Female Spayed Please list the reason for today's visit * Is the primary number the best number to reach you at today? * Yes No, I'd like to provide another number List any medications or supplements that your pet is on Is your pet microchipped? * Yes No I'm Not Sure Does your pet have previous veterinary records? * Yes No I'm Not Sure I approve any bloodwork and radiographs necessary per the doctor's recommendation * Yes, I would like to proceed with the doctor's recommendation. No, I decline these diagnostics at this time. I would like an estimate provided with the recommended diagnostics before proceeding. At High Country Veterinary Hospital, we love social media and sharing our amazing patients! Do we have your permission to post pictures of your pet(s), you and your pet(s) and/or your pet(s) and our team on Facebook, Instagram, www.highcountryvetco.com and any other marketing and/or other social media outlets we may choose to use? * Yes, you have my permission to post on social media No, you do not have my permission to post on social media Consent to Receive Text Messages * By selecting "Yes", you agree to receive messages regarding your appointments, reminders, and other relevant information related to our services. Standard message and data rates may apply. Yes, I would like to receive important updates and notifications via text message. No, I do not wish to receive text messages. I declare I am the lawful owner of all listed pets. I hereby authorize the veterinarian(s) and staff of High Country Veterinary Hospital to examine and treat my pet(s) to meet the highest standards of quality care. I assume responsibility for all charges incurred in the care of this animal. I acknowledge that my pet's medical information will not be released to anyone not indicated on this form without my express verbal and/or written permission, and understand High Country Veterinary Hospital reserves the right to refuse the release or disclosure of medical records if the account has an outstanding balance * By signing this document, I declare that all information is true and correct to the best of my knowledge. Thank you!
