New Patient Registration Form Pet Owner’s InformationName* First Name Last Name Spouse Name:Mailing Address: Mailing Address: Apt: City: St: Zip: Home Address: Home Address: Apt: City: St: Zip: Employer:Spouse’s Employer:Are you over 18 years of age? Yes No Contact Information:Primary Contact Name:Primary Contact Phone:Primary Alternate Phone:Secondary Contact Name:Secondary Contact Primary Phone:Secondary Contact Alternate Phone:Email Address: Would you like emailed reminders? Yes No Would you like text messaging? Yes No Other persons over 18 authorized to make decisions on this account:Name:Relationship:Phone:Patient HistoryAppointment Scheduled I have an appointment scheduled I do not have an appointment scheduled yet Date of appointment MM slash DD slash YYYY Time of appointment : Hours Minutes AMPM AM/PMName:Species: Canine Feline Rodent Reptile Breed:Color/Description:Sex: Male / Neutered Male Female / Spayed Female Date of birth MM slash DD slash YYYY Previous Veterinary Hospital:Date of previous vaccinations:Current medications:Special diet:Medical Conditions:Allergies to medication or vaccines:Add more Patient History Two NameSpecies: Canine Feline Rodent Reptile Breed:Color/Description:Sex: Male / Neutered Male Female / Spayed Female Date of birth MM slash DD slash YYYY Previous Veterinary Hospital:Date of previous vaccinations:Current medications:Special diet:Medical Conditions:Allergies to medication or vaccines:Add more Patient History Three Name:Species: Canine Feline Rodent Reptile Breed:Color/Description:Sex: Male / Neutered Male Female / Spayed Female Date of birth MM slash DD slash YYYY Previous Veterinary Hospital:Date of previous vaccinations:Current medications:Special diet:Medical Conditions:Allergies to medication or vaccines:Who can we thank for referring you?Do you already have an appointment? Yes No Please Select an Appointment Date* MM slash DD slash YYYY Please Select an Appointment Time7:30am (Not available on Saturday)7:45am (Not available on Saturday)8:00am (Not available on Saturday)8:15am (Not available on Saturday)8:30am (Not available on Saturday)8:45am (Not available on Saturday)9:00am9:15am9:30am9:45am10:00am10:15am10:30am10:45am11:00am11:15am11:30am11:45am12:00pm12:15pm12:30pm12:45pm1:00pm1:15pm1:30pm1:45pm2:00pm2:15pm2:30pm2:45pm3:00pm3:15pm3:30pm3:45pm4:00pm (Not available on Saturday)4:15pm (Not available on Saturday)4:30pm (Not available on Saturday)4:45pm (Not available on Saturday)5:00pm (Not available on Saturday)5:15pm (Not available on Saturday)5:30pm (Not available on Saturday)5:45pm (Not available on Saturday)I authorize Pyramid Veterinary Hospital to examine and to treat my pet. I understand that Pyramid Veterinary Hospital does not bill and that all fees are to be paid in full at time of service. Any unpaid balance will be immediately turned over to a collection agency and a $30 Administration Fee will be added to my bill.SignatureDate MM slash DD slash YYYY
