New Patient Form — The Mountain Hospital for Animals

Owner Information

The primary contact responsible for the pet's care and billing.

First Name *

Last Name *

Street Address *

City *

State *

ZIP *

Mobile Phone *

Home Phone

Email *

Preferred Contact Method

Emergency Contact Name

Emergency Contact Phone

How did you hear about us?

Pet Information

Tell us about your animal. One form per pet — submit another for each additional patient.

Pet's Name *

Species *

Breed

Color / Markings

Sex *

Male Female Unknown

Spayed / Neutered?

Yes No Unknown

Date of Birth (or estimate)

Approximate Age

Current Weight (lbs or g)

Microchip Number

Where did you get your pet?

How long have you had this pet?

Prior Veterinary Care

If your pet has seen another veterinarian, we'll request records on your behalf.

Previous Veterinarian / Clinic

Clinic Phone

Clinic City & State

Authorize records release?

Yes — please request my pet's medical history from this clinic.

Medical History

Share what you know. If you're unsure of a date, an approximation is fine.

Current Medications & Supplements

Known Allergies

Past Surgeries or Major Illnesses

Chronic / Ongoing Conditions

Last Rabies Vaccination

Last Core Vaccines (DHPP / FVRCP)

Heartworm Prevention Used

Flea / Tick Prevention Used

Last Fecal / Parasite Screen

Heartworm Test Status

Negative Positive Never tested Unknown

Diet & Lifestyle

Behavior & Temperament

This helps our staff make the visit calm and safe for your pet.

Reason for Today's Visit

Primary Concern *

Exotic Pet Husbandry

Complete this section only for reptiles, birds, small mammals, amphibians, or wildlife. Skip if your pet is a dog or cat.

Enclosure Type & Size

Substrate / Bedding

Temperature Range (°F)

Humidity (%)

UVB Lighting

Heat Source

Diet Details

Insurance & Treatment Authorization

Do you have pet insurance?

No Yes

Insurance Provider (if yes)

Emergency Treatment Authorization

Contact me before any treatment is started. Proceed with life-saving care up to the cap below. Provide all medically necessary care; bill me.

Authorization Cap ($)

Preferred Payment Method

Consent

Signature (type your full name) *

Date *

I have read and agree to the above. *