Name *

First

Last

Email *

Your primary phone number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Who else is authorized to make decisions about your pet's healthcare? If you are having a spouse/partner or someone else drop off or pick up your pet they must be an authorized person in our system. *

First

Last

Relationship

Phone Number

Pet's Name *

Species (Dog, Cat, Etc.) *

Breed *

Color *

Markings *

Weight *

Age/Date of Birth *

Sex *

Unneutered Male
Neutered Male
Unspayed Female
Spayed Female

List of prior veterinary clinics

Medical records (Rabies Certificate, Vaccine History, Laboratory Results, & Dr. Notes) are required for all new client pet(s) and must be faxed, emailed, or given to the CSR staff no later than two days prior to appointment. Medical records not received prior to two days before appointment a $35.00 records review fee may be applied to the account. This medical records requirement is the responsibility of the owner of the new client pet(s). Please make sure your name and your pet’s name is on the record or in the subject title of the email. *

I have read and accept the medical records policy.

Any known medication or vaccine allergic reactions

Any medications patient is currently taking: (Heartworm, Flea/tick Prevention, Supplements, etc.)

Any prior surgeries or known medical conditions

What is your pet temperament for pet visits?

Does your pet have a microchip for identification? *

Yes
No
I do not know

Microchip number *

Any other information that you would like us to know about your pet?

Do you have a second pet? *

Yes
No

Pet's Name *

Species (Dog, Cat, Etc.) *

Breed *

Color *

Markings *

Weight *

Age/Date of Birth *

Sex *

Unneutered Male
Neutered Male
Unspayed Female
Spayed Female

List of prior veterinary clinics

Medical records (Rabies Certificate, Vaccine History, Laboratory Results, & Dr. Notes) are required for all new client pet(s) and must be faxed, emailed, or given to the CSR staff no later than two days prior to appointment. Medical records not received prior to two days before appointment a $35.00 records review fee may be applied to the account. This medical records requirement is the responsibility of the owner of the new client pet(s). Please make sure your name and your pet’s name is on the record or in the subject title of the email. *

I have read and accept the medical records policy.

Any known medication or vaccine allergic reactions

Any medications patient is currently taking: (Heartworm, Flea/tick Prevention, Supplements, etc.)

Any prior surgeries or known medical conditions

What is your pet temperament for pet visits?

Does your pet have a microchip for identification? *

Yes
No
I do not know

Microchip number *

Any other information that you would like us to know about your pet?

Do you have a third pet? *

Yes
No

Pet's Name *

Species (Dog, Cat, Etc.) *

Breed *

Color *

Markings *

Weight *

Age/Date of Birth *

Sex *

Unneutered Male
Neutered Male
Unspayed Female
Spayed Female

List of prior veterinary clinics

Medical records (Rabies Certificate, Vaccine History, Laboratory Results, & Dr. Notes) are required for all new client pet(s) and must be faxed, emailed, or given to the CSR staff no later than two days prior to appointment. Medical records not received prior to two days before appointment a $35.00 records review fee may be applied to the account. This medical records requirement is the responsibility of the owner of the new client pet(s). Please make sure your name and your pet’s name is on the record or in the subject title of the email. *

I have read and accept the medical records policy.

Any known medication or vaccine allergic reactions

Any medications patient is currently taking: (Heartworm, Flea/tick Prevention, Supplements, etc.)

Any prior surgeries or known medical conditions

What is your pet temperament for pet visits?

Does your pet have a microchip for identification? *

Yes
No
I do not know

Microchip number *

Any other information that you would like us to know about your pet?

Payment is due in full at the time that services are performed. If your pet is admitted for medical emergency treatment into the hospital, we cannot begin to care for your pet until you have confirmed your desire to do so by 1) signing the Client Consent & Estimate Form or emergency Care Release Form and 2) paying the initial deposit of $700.00 deposit. This is our assurance that you have consented for us to proceed with the care of your pet. We accept cash, Visa, Mastercard, Discover, and CareCredit payments. We neither extend credit nor bill for services, and all open invoices are sent to collections after 45 days unless prior arrangements are made. *

I have read and accept the financial policy.

Signature *

Clear Signature

New Client Form

New Client Center

Ready for a Visit?

Contact

Location

Hours

Emergency Information

Animal Specialty & Emergency Center of Brevard

Animal Specialty & Emergency Hospital

Have a Question?