New Client Form Owner InformationName First Last PhoneEmail Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Co-Owner's Name First Last Co-Owner's PhoneEmergency Contact (Name and Number)Emergency Authorization (Choose One)(Required) Basic Stabilization Only (until you are able to be contacted) Any Amount of Treatment Necessary (see paragraph above) Our doctors and staff strive to provide the best care possible for your pet. Medical emergencies do sometimes occur even with completely healthy pets. Should an emergency occur, and we are unable to reach you or your emergency contact, please elect your wishes regarding emergency stabilization. Emergencies can be costly due to extensive treatments and medications. Please understand that emergency stabilization can involve fees in excess of $400. Please choose one of the following treatment options in case of an emergency. Cancellation Policy Authorization(Required) I have read and understand the Missed or Cancelled Appointment Policy. *Failure to abide by this policy may result in a fee. Missed or Cancelled Appointment Policy: We understand that there are times when you must miss an appointment due to unforeseen circumstances. However, when you do not call to cancel an appointment or reschedule in a timely manner, you may be preventing another patient from getting much needed medical care. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly “full” appointment schedule. Please help us to avoid having to turn patients away by cancelling within 24 hours of your appointment time. *Failure to abide by this policy may result in a fee.Payment Policy(Required) I have read and understand the Payment Policy. Payment is due at the time of services rendered. For your convenience we accept, cash, checks ($30 returned check fee), all major credit cards and Care Credit. A valid driver’s license number is required for check writing privileges. By authorizing below, I understand that I am responsible for charges incurred for animal medical services and that payment of the entire balance is due upon release of the pet. If for any reason my method of payment is declined (check returned, credit card charges declined, etc), I understand that I am responsible for any applicable fees, charges and collection expenses incurred by Oceanside Veterinary Clinic, P.A. Pet InformationPet First Name OnlyPet SpeciesPet BreedPet ColorPet Sex Male Female Neutered Male Spayed Female Birthdate (Estimate if Uknown) MM slash DD slash YYYY Behavior at the Vet My pet thinks the vet is so much fun! My pet thinks the vet is a little scary, but they do ok. My pet thinks that basic things like an exam are ok, but if there are needle pokes or restraint involved, my pet gets upset. My pet needs to wear a muzzle or take oral premedication for visits. My pet requires full sedation to be at the vet’s office. I am unsure because this is the first time I will be with my pet at the vet. Please describe how your pet has reacted during previous visits to the vet. Select all that apply.Do we have permission to take pictures of your pet and post them to our social media? Yes No Please list the name and phone number of all of your pet's previous health care providers. We will contact them directly to have your pet's medical records transferred. If your pet has never received veterinary care or vaccines, please enter N/A.(Required)Reason for your visit (choose all that apply)(Required) Puppy/Kitten Visit Preventative Care/Annual Vomiting/Diarrhea Coughing/Sneezing Itching/Scratching Ear Issues/Shaking Head Urinary Issues Eye Issues Lethargy Second Opinion Other If other, please describe:Please describe any additional details associated with your appointment request (duration or severity of symptoms, current medications or treatments, etc).(Required)CAPTCHA Δ
