Have you ever brought a pet to Andover Animal Hospital before? *

Yes
No

Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

How Would You Prefer To Be Contacted? *

Is there a spouse/partner/family member who should be listed on your account? *

Yes
No

Name *

First

Last

Phone *

In case of emergency... Is there anyone else (besides above listed contacts) who should be listed on your account who has ongoing permission to make medical decisions for your pet(s)? *

First

Last

Phone

How did you hear about us?

Please tell us who we may thank for your referral:

Pet's Name *

Species (dog, cat) *

Please upload a picture of your pet below:

Click or drag a file to this area to upload.

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No
Unsure

Do you already have a scheduled appointment? *

Yes
No
I scheduled an appointment through your website/Facebook.

Appointment Date and Time (If not applicable, please put N/A for both.) *

Date

Time

Previous Veterinarian(s) *

If none, please let us know that!

Please upload previous veterinary records:

Click or drag a file to this area to upload.

Do you have more than one pet at home?

Yes
No

Pet #2 - Name *

Species (dog, cat) *

Please upload a picture of your pet:

Click or drag a file to this area to upload.

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No
Unsure

Pet #3 - Name *

Species (dog, cat) *

Please upload a picture of your pet:

Click or drag a file to this area to upload.

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No
Unsure

Pet #4 - Name *

Species (dog, cat) *

Please upload a picture of your pet:

Click or drag a file to this area to upload.

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No
Unsure

We love social media! Do we have your permission to post pictures of your pet(s), you and your pet(s) and/or your pet(s) and our team on Facebook, Instagram, Twitter, our website, and any other marketing and/or other social media outlets we may choose to use? *

Yes
No

Andover Animal Hospital uses email, text, and our own hospital app for communications regarding our patient reminders for health care needs. Do we have your permission to contact you via email, text, and/or our app regarding these reminders? *

Yes
No

FINANCIAL POLICY: Our office accepts Visa, Mastercard, Discover, and American Express. We also accept cash and checks (only with verification of valid driver's license or other ID at time of payment). In addition, we also offer several 3rd party financing options for our clients via CareCredit. We accept a variety of CareCredit plans based on the total transaction amount for your pet. CareCredit requires that the card be present every time and that two forms of identification are verified. We appreciate your understanding of our desire to protect your account/identity. As financing options are offered, we cannot offer additional in-house payment plans for our services. Clients needing additional financial support are encouraged to apply for CareCredit with a co-signer. Full payment is due at the time of service. This includes any charges/fees agreed to by my authorized proxy. Our team is happy to provide any client with a written treatment plan prior to services being rendered. The client will be responsible for a 1.5% monthly finance charge on accounts over 30 days and any collection and/or legal fees on accounts over 90 days. There will be a $35 returned check fee for any NSF check payments. Your signature below indicates your agreement with these policies.

By signing this document, I declare I am the lawful owner of all listed pets, and all information is true and correct to the best of my knowledge. I hereby authorize the veterinarian(s) of Andover Animal Hospital to examine, prescribe for or treat my pet(s) to the best of their abilities. I assume responsibility for all charges incurred in the care of this animal. I acknowledge that medical information will not be released to anyone not indicated on this form without my express verbal and/or written permission (except another veterinary facility). *

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