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1302 Hamburg Turnpike, Wayne, NJ (973) 831-2426

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New Client / New Pet Form

"*" indicates required fields

Please make a selection*

I am a new client

I am an existing client adding a new pet

(This field is required)

NEW CLIENT REGISTRATION

Date*

Owner*

First Last

Address*

Street Address City State ZIP Code

Email 1*

Home Phone

Work Phone

Cell Phone*

Would you like to add a spouse or co-owner?*

Yes

No

Please select one*

Spouse

Co-owner

Name

First Last

Cell Phone*

Email*

Emergency Contact Name*

Emergency Contact Phone#*

How did you learn of our clinic?*

Recommendation

Website / Online Search

Phone Directory

Sign

Other

By whom?*

Please specify*

Reason for visit*

I WANT TO ADD A NEW PET

Name*

First Last

Phone*

Email 2*

PET HEALTH HISTORY

Name of pet*

Species*

Dog

Cat

Other

What species is your pet?*

Breed

Color

Birthday (Or approximate age if unknown)*

Gender*

Male

Female

Spay / Neutered?*

Yes

No

Do you have copies of your pet's medical records?*

Yes

No

You can upload your pet's records here

Drop files here or

Accepted file types: jpg, gif, png, pdf, jpg, gif, png, pdf, Max. file size: 60 MB.

Please bring your pet's records if you have trouble uploading the files here.

If not, whom may we contact to get a copy?

(Please include practice name, phone and address)

Pet’s Current Medications

Describe your pet’s diet

Do you have any concerns about your pet’s current health?*

Yes

No

Please elaborate*

Do you want to add another pet?*

Yes

No

Second Pet Section

Name of pet*

Species*

Dog

Cat

Other

What species is your pet?*

Breed

Color

Birthday (Or approximate age if unknown)

Gender*

Male

Female

Spayed / Neutered*

Yes

No

Do you have copies of your pet's medical records?*

Yes

No

You can upload your pet's records here

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 60 MB.

Please bring your pet’s records if you have trouble uploading the files here.

Pet’s Current Medications

You can click the plus sign to add more medications. Please use one line for each medication.

Describe your pet’s diet

Do you have any concerns about your pet’s current health?*

Yes

No

Please elaborate*

AUTHORIZATION

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment.*

I do

Signature

Accepted Forms of Payment: Cash, Check, Mastercard, Visa, Discover

Email

This field is for validation purposes and should be left unchanged.

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Tri-County Animal Hospital

1302 Hamburg Turnpike,
Wayne, NJ 07470

(973) 831-2426

Veterinarian serving Wayne NJ, Little Falls, New Jersey and the surrounding areas.

https://wayneanimalhospitalnj.com/

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