Please complete this form carefully and thoughtfully. All information is kept confidential and allows us to provide the best service for your pet needs.

Date *

How did you hear about us? *

Please allow us to verify/photocopy your driver's license, state-issued identification card, or military identification card. If you do not wish to provide this information, we require prepayment for all office visits, surgeries, procedures, and products. Your SSN/DL numbers are NOT entered into our software.

Name *

First

Last

SSN *

Driver's License Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

What type of number is this? *

Home
Cell
Work

Secondary Phone

Email *

Best method of communication *

Call
Text
Email

Employer *

Employer Address *

Address Line 1

Address Line 2

City

State

Zip Code

If you are a military service member, please write more than just “US Navy or US Airforce.” Please include your unit, building number, and military mailing address. This is to CONTACT you in the event other methods of contact have failed.

About your pet's privacy: We do not discuss your pet's case with any person who is not a veterinarian or veterinary staff without your permission. If there is anyone else permitted to pick up/drop off/or discuss your pet's disposition, please provide their information below.*

*You understand that the pet (s) listed here are your legal and financial responsibility regardless of who may be listed as an additional contact.

Name and other contact or identifying information

Payment in full is due at the time of treatment for services rendered. (No postdated checks or "courtesy holds" on checks will be accepted.) The following forms of payment are accepted: cash, checks, Visa, MasterCard, Discover, American Express, and debit cards, as well as CareCredit. *

I have read and understand

If I declined to provide a photocopy of my valid ID and/or SSN, Northwood Hills Animal Hospital will provide an estimate and require prepayment for expected services. (In the case of an emergency or your pet's illness isn't clear, we will require a deposit of $300.00 prior to treatment.) *

I have read and understand

I understand that every effort will be made to provide me with an estimate for treatment and services; however, it is my responsibility to keep abreast of all charges to my account while my pet(s) are in the care of this facility. *

I have read and understand

My pet must be current on all vaccines (distemper combo, Bordetella, and rabies/feline upper respiratory, FeLV, and rabies) to board or be groomed at NHAH. If my pet was vaccinated elsewhere by a licensed veterinarian, it is my responsibility to provide proof. *

I have read and understand

It is my responsibility to notify Northwood Hills Animal Hospital if I am unable to pick up my pet on the agreed-upon date. If there is no contact within 14 days after the agreed-upon date, my pet(s) will be considered abandoned and appropriate action will be taken. *

I have read and understand

Northwood Hills Animal Hospital has my permission to share photos of my pet on their social media. I understand only positive information will be shared; no details that identify me, my pet, or my pet's medical condition in any specific way will be shared (usually, these photos are simply candid “cute” snapshots taken by staff members). *

I give permission
I do not give permission

I understand Northwood Hills Animal Hospital reserves the right to refuse any requested services, including euthanasia if the veterinarians (and staff) deem it medically unnecessary. *

I have read and understand

I am provided copies of all documentation of physical examinations and surgeries upon payment of my account. Should I require duplicate copies in the future, I will be charged a per-page fee to reproduce the information. *

I have read and understand

Pet Information

Pet's Name *

Species *

Dog
Cat
Other

If other, please specify *

Breed *

Color/Markings *

Age/Date of Birth *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Name and phone number of veterinary facility where pet was most recently treated *

May we contact previous veterinary facility for patient records? *

Yes
No

Add another pet? *

Yes
No

Pet's Name *

Species *

Dog
Cat
Other

If other, please specify *

Breed *

Color/Markings *

Age/Date of Birth *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Name and phone number of veterinary facility where pet was most recently treated *

May we contact previous veterinary facility for patient records? *

Yes
No

Add another pet? *

Yes
No

Pet's Name *

Species *

Dog
Cat
Other

If other, please specify *

Breed *

Color/Markings *

Age/Date of Birth *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Name and phone number of veterinary facility where pet was most recently treated *

May we contact previous veterinary facility for patient records? *

Yes
No

Please list any other pet(s) living in the household

By signing below, I hereby authorize Northwood Hills Animal Hospital to examine, prescribe for, or if necessary, perform surgery upon my pet(s).

Signature *

Please note: We will be closed on Saturday, July 2nd and Monday, July 4th in observance of Independence Day!

New Client Form

Thank you for choosing Northwood Hills Animal Hospital!

Pet Information

We promise to be a partner in your pet’s health.

We give every single pet the personalized attention they deserve.

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