New Patient Form

Name *

First

Last

Email *

Has any information changed since we’ve last seen you? If so please fill out the below, if not skip and go straight to the patient section to fill out information?

Daytime Phone Number

Evening Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Secondary Owner

First

Last

Pet's Name *

Breed *

Color *

Age or Birthday *

Sex *

Male
Neutered Male
Female
Spayed Female

Are your pets vaccines current? *

Yes
No

Previous Veterinarian

May we contact them for records?

Yes
No

Upload any records you have here:

Click or drag a file to this area to upload.

Please list any medications your pet is currently on.

Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here:

How did you hear about us?

Whom may we thank?

Please explain:

I grant permission to Huntington Beach Pet Hospital, its employees and authorized representatives, to take photographs and/or video of me and/or my pet(s), to copyright, use and publish the same in print and/or electronically. Huntington Beach Pet Hospital may also use my pets' story, including relevant medical information. I agree the Huntington Beach Pet Hospital may use such photographs, videos or stories including me and/or my pet, with or without names, and for any lawful purpose, including for example such purposes as social media, publicity, advertising, and other web content. *

Yes, I grant permission
No, I do not wish to have my pet photographed

I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Huntington Beach Pet Hospital and that charges are due and payable at the time of service unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Huntington Beach Pet Hospital's collection agency and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges. *

I have read this statement and agree.
I have read this statement and disagree.

Please complete the form below and a member of our team will get back to you as quickly as possible with any questions. If this is an emergency situation, please call us at 714-962-3639.

Has any information changed since we’ve last seen you? If so please fill out the below, if not skip and go straight to the patient section to fill out information?