New Client Intake Form

Owner's Name
Client Name*
First Last
Spouse/Authorized Party*
First Last
Date of Birth*
This is required by law for all controlled substance reporting. If you wish to show it to a staff member rather than write it, please notify the employee at checking in. Thank you
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone*
Secondary Phone
Emergency Contact
Name/phone # if different from above
Email*
Enter Email Confirm Email
Are you allergic Latex or other commonly used hospital products?
- No
- Yes
if Yes, please list your allergy:
Referral / Primary Care Veterinary Information
Referral Veterinarian
Referral Veterinary Hospital (name):
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Referral Hospital phone number
Pet Information
Pet's Name*
Pet's Age
Sex
Species*
or if other species
Previous Health History
Patient Allergies (food/environmental)
Current Specialty Diet (if applicable)
Medications
Please list all current medications below by: medication name, milligram given/ amount and time.
Confidentiality
All information is for confidential use by Healing Hearts Emergency Animal Hospital only. This information will not be sold or reused. Thank you, Healing Hearts Emergency Animal Hospital Management.
Medical Release Form
Owner Name
First Last
From Date
Date Format: MM slash DD slash YYYY
To Date
Date Format: MM slash DD slash YYYY
Hospital Name
Hospital Email/ Fax
Medical Records Release Form
I, the undersigned do hereby grant my permission for the release of any or all medical documentation contained in the medical records from the dates below, of my pet listed below, to the following veterinary practice:

I agree to the Medical Records Release Form policy.
Photo/Video Social Media Release Form
We enjoy sharing photos and videos of our patients and their families on social media and occasionally on print materials, advertising, and signage for the hospital. However, we will never do so without your consent.
Please select all that apply:
- Healing Hearts Emergency Animal Hospital may take photos and/or videos of my pets
- Healing Hearts Emergency Animal Hospital may take photos and/or videos of me
By selecting one or both above, you grant Healing Hearts Emergency Animal Hospital, its representatives, and employees the right to take photographs and/or videos of me and/or my pet, and to copyright, use, and publish the same in print and/or electronically.

You also agree that Healing Hearts Emergency Animal Hospital may use such photographs and/or videos of me and/or my pet with or without my name and for any lawful purpose, including, for example, publicity, illustration, advertising, and web content.
Please select all that apply:
If you prefer not to have you or your pet photographed or recorded on video, please select one or both options below
- Healing Hearts Emergency Animal Hospital may NOT take photos and/or videos of my pets
- Healing Hearts Emergency Animal Hospital may NOT take photos and/or videos of me.
Pet's Name*
Date*
Date Format: DD slash MM slash YYYY
Client Name*
First Last
Client Signature*
I consent to the selections above

New Client Intake Form

Owner's Name

Referral / Primary Care Veterinary Information

Pet Information

Confidentiality

Medical Release Form

Photo/Video Social Media Release Form

Contact Us

Address

Contact

Hours