Northgate Animal Hospital - New Client Form

Northgate Animal Hospital - Quality Care for Your Companion Animals, Convenience for You

Complete this form online and all you will need to do is sign the completed forms at your first appointment. Click submit to send the form information to Northgate Animal Hospital.

Owner Name

2nd Owner Name
(spouse, partner, etc...)

Street Address

City, State, Zip

Home Phone

Work Phone

Occupation

Employer

Cell Phone

E-mail

Send e-mail
reminders?

Yes No

Do you qualify for our active duty military discount?

Yes, Branch: No

Alternate Contact:

Alternate Contact Name

Alternate Contact's Relation
to You

Alternate Contact's Phone

Is this person authorized to make decisions about your pet’s health?

Yes No

How did you first learn of
our hospital?

Were you referred by someone?

# of Pets in Your Household

Pet Information:

Pet Name

Species

Dog Cat Other

If Other Species

Breed

Description/ Color

Sex

Male Female

Date of Birth

Neutered/Spayed?

Yes No

Microchipped?

Reason for Visit

Previous Hospital/ Vet

Vaccinations Current?

Yes No

Current Medications

Describe your pet's Diet

Please check any symptoms or problems you have noticed about your pet

	Bad Breath
	Behavior Problems
	Bleeding Gums
	Breathing Problems
	Coughing
	Depressed
	Diarrhea
	Eye Problem
	Lack of Appetite
	Limping
	Loss of Balance
	Scooting
	Scratching Excessively
	Shaking Head
	Sneezing
	Thirst and/or Urination Increase
	Vomiting
	Weakness
other symptoms (please explain)

Disclaimer
(read-only)

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment.

When you are finished, click submit to send the form information