New Client Form

Welcome! The following information will help us to set up and maintain a file for your pet. Thank you!

YOUR INFORMATION

Title

Last

First

M.I.

Home Address

Apt #

City

Zip

Home Phone

Cell

Pref Contact

Birth Date

Month

Day

Year

Drivers Lic #

Employer

Employer Phone

Employer Address

Employer City

Employer Zip

RESPONSIBLE PARTY (In Case of an Emergency)

Relation

Title

Last

First

Phone

NEAREST RELATIVE not living with you (other than listed above)

Title

Last

First

Address

Apt #

City

Zip

OTHER PERSON(S) AUTHORIZED TO PRESENT PETS FOR TREATMENT

Title

Last

First

Phone

Title

Last

First

Phone

PET INFORMATION

Pet’s Name

Date of Birth

Month

Day

Year

Breed

Color

Sex

Vaccinations Current?

If yes, where?

PET INFORMATION

Pet’s Name

Date of Birth

Month

Day

Year

Breed

Color

Sex

Vaccinations Current?

If yes, where?

Photo Release

I agree that, Newport Harbor Animal Hospital and its employees may take and use photographs of me and/or my pets, with or without my name, only for such purposes as publicity, illustration, advertising, and Web content.

How Did You Find Our Hospital?

It is our policy to provide you with an estimate of charges for any medical treatment, surgery, or hospitalization that will be provided. A deposit may be required prior to treatment, based upon the amount of the estimate.
Acceptable forms of payment are: Cash, Visa, MasterCard, American Express, Discover, and CareCredit.

*ALL CHARGES ARE DUE AND PAYABLE UPON PATIENT’S RELEASE*

New Client Form

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