Owner Information

Primary Owner First Name

Primary Owner Last Name

Primary Owner Email

Primary Owner Mobile Phone

Primary Owner Home Phone

Secondary Owner/Authorized Agent Full Name

Secondary Owner/Authorized Agent Mobile Phone

Secondary Owner/ Authorized Agent Email

Address

City

State

Zip Code

Primary Owner Date of Birth

How did you hear about us?

Primary Care Veterinarian

Internet

Friend / Family

Community Event

Signage

Printed Publication

Radio

Other

Emergency Contact

Primary Emergency Contact Name

Primary Emergency Contact Phone

Secondary Emergency Contact Name

Secondary Emergency Contact Phone

Do you authorize your emergency contact(s) to make urgent treatment decisions if you are unreachable?

Yes

No

Do you authorize your emergency contact(s) to receive patient information in addition to your primary care veterinarians?

Yes

No

Patient Information 1

Pet Name

Birth Date / Age

Breed / Other Species

Color

Presenting problem, special needs, concerns

Has your pet been previously diagnosed with a disease or ongoing medical condition (Ex: Diabetes, Hypothyroidism, Cushing's Disease, Heart murmur)?

Yes

No

If yes, please describe.

Is your pet currently taking any medications (including flea, tick and heartworm preventatives)?

Yes

No

If yes, please list the name and dose of each medication your pet is taking:

Patient Information 2

Pet Name

Birth Date / Age

Breed / Other Species

Color

Presenting problem, special needs, concerns

Has your pet been previously diagnosed with a disease or ongoing medical condition (Ex: Diabetes, Hypothyroidism, Cushing's Disease, Heart murmur)?

Yes

No

If yes, please describe.

Is your pet currently taking any medications (including flea, tick and heartworm preventatives)?

Yes

No

If yes, please list the name and dose of each medication your pet is taking:

Patient Information 3

Pet Name

Birth Date / Age

Breed / Other Species

Color

Presenting problem, special needs, concerns

Has your pet been previously diagnosed with a disease or ongoing medical condition (Ex: Diabetes, Hypothyroidism, Cushing's Disease, Heart murmur)?

Yes

No

If yes, please describe.

Is your pet currently taking any medications (including flea, tick and heartworm preventatives)?

Yes

No

If yes, please list the name and dose of each medication your pet is taking:

Primary Veterinarian Information

Please fill this section in if your pet currently or has previously received primary care at another veterinary hospital. By listing your current/former primary care veterinarian, you are authorizing Shane Veterinary Medical Center to request and/or release patient information to the primary care hospital or veterinarian.

Primary Care Facility

Primary Care Veterinarian(s)

By submitting this form, I hereby authorize Shane Veterinary Medical Center to render medical care for my pet(s) as deemed necessary by the veterinarian. I understand that no guarantee can be given to the outcome of treatments and take it as my responsibility to comprehend any risks involved. I agree to pay for the cost of all services to which I consent to by written or verbal estimate. I understand that a deposit is required before diagnostics and treatments can be initiated and that payment in full is required prior to discharge of patient from Shane Veterinary Medical Center.

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New Patient Form

Option 1

Complete Online

Option 2

Complete on Arrival

New Patient Form

Owner Information

Emergency Contact

Patient Information 1

Patient Information 2

Patient Information 3

Primary Veterinarian Information

New Patients Welcome