New Client Intake Form

  • Owner's Name

  • 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
  • Name/phone # if different from above
  • Pet Information

  • 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

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • 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.
  • 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.
  • If you prefer not to have you or your pet photographed or recorded on video, please select one or both options below
  • Date Format: DD slash MM slash YYYY