New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

Form - New Client

Primary Owner (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Home Phone (required)
Phone TypePhone Number (required)
Work Phone (required)
Phone TypePhone Number (required)
Cell Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Which is the best way to contact you during the day?

Which is the best way to contact you after business hours?

Employer:

Occupation:

Drivers License Number,Expiration,State

How did you hear about us? :
Pet's Name (required)

Age: Years, Months

Breed:

Type of Pet (required) :
Color:

Markings:

Sex: (required) :
Neutered/Spayed
Yes
No

Current on Vaccines
(Has your pet been vaccinated in the past three years?)
Yes
No

Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No

Emergency Treatment Authorization/Consent (required)
(In the event of an emergency, do you authorize treatment of your pet(s) if every attempt made to contact you was unsuccessful?)
Yes
No

Please list any additional pets here

Please Read
I, the undersigned, and owner or authorized agent of the above mentioned pets, do hereby authorize Aloha Animal Hospital to perform such examinations, diagnostic tests and treatments necessary. I further agree to be financially responsible for all costs for such procedures and treatments. I understand that full payment is due at the time services are rendered. I understand that abandonment of animals does not relieve me of this financial obligation. Failure to pay bills on time may result in billing, financial charges and/or costs of any collection fee incurred.
I have read this statement and - (required)
I Agree
I Disagree


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