Name: Veterinarian
Brand: Newport Harbor Animal Hospital

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

Your Information

Title

Last Name

First Name

M.I.

Home Address

Apt #

City

ZIP

Home Phone

Cell

Email Address

Pref Contact

Home

Cell

Text

Birth Date

Drivers License #

Employer

Employer Phone

Employer Address

Employer City

Employer ZIP

Responsible Party (In case of an emergency)

Relation

Title

Last Name

First Name

Phone

Nearing relative not living with you (Other than listed above)

Title

Last Name

First Name

Address

Apt #

City

ZIP

Other person(s) authorized to present pets for treatment

Title

Last Name

First Name

Phone

Title

Last Name

First Name

Phone

Pet's Information

Pet's Name

Date of Birth

Breed

Color

Sex

Male

Female

Spay/Neuter

Yes

Vaccinations Current?

Yes

If yes, where?

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.

Our Veterinary services utilize ScribbleVet, a tool from Kairo Care, Inc., which records your pets’ appointments for improved clinical documentation. By agreeing to this agreement, you consent to: Appointment Recording, Usage Rights & Age Confirmation & Understanding. You agree that your vet appointments may be recorded, if you do not want them recorded, please let us know. You grant us permission to share these recordings and other materials you provide for the purpose of improved clinical documentation. You affirm that you are at least 18 years of age. By authorizing the above, you also authorize consent for any persons listed on the account.

How did you find our hospital?

If you found us by referral, please give us the name of the person who referred you:

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

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Make your getaway stress-free and reserve boarding for your pet! Call us today to confirm your boarding reservation.

New Client Form

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

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.

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

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