Welcome! The following information will help us to set up and maintain a file for your pet. Thank you! YOUR INFORMATION Title - None -Mr.Mrs.Miss Last First M.I. Home Address Apt # City Zip Home Phone Cell Email Pref Contact - None -HomeCellTextEmail Birth Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019 Social Security # Drivers Lic # Employer Employer Phone Employer Address Employer City Employer Zip RESPONSIBLE PARTY (In Case of an Emergency) Relation - None -Spouse or PartnerParentOther Title - None -Mr.Mrs.Miss Last First Phone NEAREST RELATIVE not living with you (other than listed above) Title - None -Mr.Mrs.Miss Last First Address Apt # City Zip OTHER PERSON(S) AUTHORIZED TO PRESENT PETS FOR TREATMENT Title - None -Mr.Mrs.Miss Last First Phone Title - None -Mr.Mrs.Miss Last First Phone PET INFORMATION Pet’s Name Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year199920002001200220032004200520062007200820092010201120122013201420152016201720182019 Breed Color Sex - None -MaleFemaleSpay/Neuter Vaccinations Current? -Select-YesNo If yes, where? PET INFORMATION Pet’s Name Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year199920002001200220032004200520062007200820092010201120122013201420152016201720182019 Breed Color Sex - None -MaleFemaleSpay/Neuter Vaccinations Current? -Select-YesNo If yes, where? Photo Release -Select-Yes, NHAH may take and use photos as described aboveNo, NHAH may NOT take and use photos as described above 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? -Select-Drive By / LocationGoogle / Internet SearchBreederWebsite / BlogYelpVeterinary ReferralYellow PagesEvent / TradeshowPersonal ReferralFacebookInstagramOther 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*
