New Client/Patient Intake Form | Oceanside Animal Hospital, Sandwich MA

First Name:

Last Name:

Spouse/Partner's Name:

Street Address:

PO Box:

City, State, Zip Code:

Primary Phone Number:

OK to Receive Texts?

Secondary Phone Number:

Ok to Receive Texts?

Email Address:

Who Can We Thank for Referring You to us?

Pet Information

Pet's Name:

Species:

Breed/Exotic Species:

Sex:

Male Female

Date of Birth or Age:

Colour:

Is your pet spayed or neutered:

Yes No

Is your pet easily approached by strangers:

Yes No

If not, what should we be aware of?:

Release of Medical Records

I authorize Oceanside Animal Hospital to obtain my named pets medical history and records to best treat my pet.

Yes, I authorize the release of my pet's medical records.

Veterinarian/Animal Hospital Name:

City/State:

Social Media Release

I authorize the staff at Oceanside Animal Hospital to release portions of my pet's medical history and record, including personal recollections, radiographs, photographs and/or video images on social media platforms, television, radio or print media for public education purposes and agree to its use in this manner. I agree not to file any claim or lawsuit against the above parties with respect to the release of this information including, without limitation, any claims based on negligence of the parties who release this information.

Yes, I authorize the Oceanside Animal Hospital to use the above collateral on social media

Additional Pet Information

Additional Pet 1:

Pet's Name:

Species:

Breed/Exotic Species:

Sex:

Male Female

Date of Birth or Age:

Colour:

Is your pet spayed or neutered:

Yes No

Is your pet easily approached by strangers:

Yes No

If not, what should we be aware of?:

Additional Pet 2:

Pet's Name:

Species:

Breed/Exotic Species:

Sex:

Male Female

Date of Birth or Age:

Colour:

Is your pet spayed or neutered:

Yes No

Is your pet easily approached by strangers:

Yes No

If not, what should we be aware of?:

Additional Pet 3:

Pet's Name:

Species:

Breed/Exotic Species:

Sex:

Male Female

Date of Birth or Age:

Colour:

Is your pet spayed or neutered:

Yes No

Is your pet easily approached by strangers:

Yes No

If not, what should we be aware of?:

Additional Pet 4:

Pet's Name:

Species:

Breed/Exotic Species:

Sex:

Male Female

Date of Birth or Age:

Colour:

Is your pet spayed or neutered:

Yes No

Is your pet easily approached by strangers:

Yes No

If not, what should we be aware of?: