Owner's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Which number is best to reach you? *

Home
Cell

Can you receive text messages? *

Yes
No

Email *

Add a Co-Owner? *

Yes
No

Name *

First

Last

Home Phone

Cell Phone

Previous Vet:

Previous Vet's Phone Number

Whom should we thank for referring you?

PET HEALTH HISTORY

Pet's Name *

Sex *

Male
Female

Neutered/Spayed? *

Yes
No

Breed *

Color *

Birthdate or Age *

Current Medications

Please bring and give any medical records/vaccine records to the receptionists to make copies.

DIET AND ENVIRONMENT

What food does patient currently eat? *

Amount & Frequency? *

Is your pet on any dietary supplements *

Yes
No

If so, what kind and what dosage? *

Does your pet consume table food? *

Yes
No

Please explain *

Is your pet primarily indoor or outdoor? *

Indoor
Outdoor

Are there any other animals in the household? *

Yes
No

Please describe *

Do you have your pet groomed or boarded outside of your home? *

Yes
No

If so, how often? *

Do you travel outside of Pennsylvania with your pet? *

Yes
No

If so, where? *

PAST HISTORY

Has your pet had any prior illnesses, accidents, or surgeries *

Yes
No

Please explain.

Is your pet aggressive or fearful around strangers? *

Yes
No

Please explain. *

Is your pet on heartworm, flea/tick preventatives? *

Yes
No

How frequently? *

Year-Round
Seasonally

Please list any other medications or supplements your pet receives.

Does your pet have any known allergies to any medications? *

Yes
No

If yes, please list: *

Has your pet ever had a reaction to any vaccines? *

Yes
No

If yes, please list and explain: *

FINANCIAL POLICIES

At North Fork Veterinary Clinic we strive to provide timely quality veterinary care for our patients. We can continue to offer such care and maintain a well-equipped properly staffed facility only if we receive prompt payment for our services and products.

Full payment is due when services are rendered or inventory items are dispensed. We accept cash, personal checks, Care Credit, and major credit cards. Writing a check when insufficient funds are available is illegal. A fee of $35 will be due immediately for all returned checks and the privilege of writing a check will be revoked. Post-deposit checks are not accepted.

If you are unable to pay your bill and request a payment plan, we will process a Care Credit application with you. Care Credit is a medical credit company that provides full payment for veterinary care for eligible clients and accepts monthly payments until the balance is paid in full.

Doctors may require a deposit of up to 50% of an estimate upon admission of a pet for non-routine procedures or surgeries and critical medical cases. This will be decided on an individual basis. The remaining balance will be due the day the pet is discharged. Our doctors or technicians will provide you with an estimate of charges for surgeries and medical admissions. You may also request an estimate for routine care such as vaccines, heartworm protection, and intestinal parasite control before services are rendered.

If you are unable to pay for all recommended services and inventory items, the doctor can help you decide which are most important for your pet and which can wait until you are able to provide payment. If you are concerned about your ability to financially care for your pet, we strongly recommend you consider a pet insurance policy.

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 have read and agree.

I understand that payment is ALWAYS DUE IN FULL at time of service. A deposit of 50% of the treatment plan may be required before treatments or hospitalization of your pet. I recognize that financial concerns should be discussed PRIOR to examination and treatment. *

I have read and agree.

Do we have your permission to share your pet’s image and story on our social media, website, and other forms of related media? *

Yes
No

I authorize my emergency contact (other than myself) to pursue treatment if I am unavailable. Your emergency contact must be an adult over the age of 18. *

I have read and agree

Emergency Contact *

First

Last

Emergency Contact Phone *

Owner's Signature *

Clear Signature

Date *

File Upload

Click or drag files to this area to upload. You can upload up to 5 files.

New Patient Registration Form

New Patient Registration Form

Get In Touch

Compassionate care for the animals of Brookville, PA and the surrounding communities.

Contact Info

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Hours

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