New Client Intake Form

Owner Information

Home Address*

Please provide a physical address of residence, no PO Box addresses will be accepted.

Mailing Address (If different from above)

You may provide a PO Box address here if you do not receive your mail at your residence.

Contact Numbers

Primary Care Veterinary Information

By providing the information below you agree to the release of your pet's medical history to Healing Hearts Emergency Animal Hospital.

Pet Information

How did you hear about us?*

Discount Qualification

• Senior Citizen (65 years +)
• Military (Active/Retired/Veteran)
• First Responder (Fire/Police/Nurse/EMT)
• Veterinary Professional (DVM/Vet staff)

Photo/Video Social Media Release Form

By signing below, you grant Healing Hearts Emergency Animal Hospital permission as described. We may use photos/videos of you and/or your pet for lawful purposes including publicity, illustration, advertising, and web content.

• Permission to take photos/videos of my pets
• Permission to take photos/videos of me
• I DECLINE permission to take photos/videos of my pets or of me

Consent & Signature

• I consent to the selections above and the terms and contion.

All information is for confidential use by Healing Hearts Emergency Animal Hospital only. This information will not be sold or reused.