New Patient Form

Name

Phone

Email

Address

City

State

Zip

Microchip Number

Pet's Name

Age (DOB)

CanineFeline

Breed

MaleFemale

SpayedNeutered

Is your pet aggressive? YesNo

Color

Approximate Weight (lbs)

What is the main health concern you have about your pet?

How did you hear about us?

Do you have a regular veterinarian? If so, please list their name of clinic name and contact information

I authorize Dr. Laura McMahan to examine, prescribe for, and treat the above pet. I assume responsibility for all charges incurred in the care of my pet listed above. I also understand that all professional fees are due at the time services are rendered.

Are you ok with HousePaws sharing images or events on our social media page/website? YesNo

Would you like to subscribe to our newsletter? YesNo

Signature of responsible party: (Please sign below.)

The information on this form is confidential and is to be used only by this veterinarian to provide care for your pet.