New Patient Registration Form Owner / CaregiverPlease provide the information below as completely as possible. All information is strictly confidential.Owner / Caregiver*Partner / SpouseAddress* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell PhoneAlternate PhoneDriver's License #Email* EmploymentPet InformationPet's Name*Species*Breed*Age / Birthdate*Gender*Color / Markings*Spayed / Neutered?* Yes No Unknown Are Vaccinations Current? Yes No Unknown Referral InformationReferral Veterinarian*Clinic Name*PhoneDo you have X-raysNotesStatement Of OwnershipBy checking below you certify that you are the owner and or agent of the above animal and have the authorization to consent to treatment if and when it is needed.Confirmation* I agree Type of pet activity* Companion Working Performance athlete Primary activitiesHow did you hear about us?* Internet Friend Veterinarian Newspaper ad Newspaper article TV Other If other, please tell us:General Medical HistoryDiet: Type,frequency , amountPast pertinent medical history (not related to current problem)*Current medications, supplements, and nutraceuticals (including aspirin or any other human products)*Previous surgeriesHistory of Current ProblemDate of onset of problem or surgery*History of present problem*Please describe your companion’s activity level before and after the onset of this injury or illness:*What are your goals with treatment of this problem?*Authorization: I hereby authorize Peak Performance Veterinary Group to examine, prescribe for, and treat the above-mentioned pet. I assume all charges incurred in the care of the animal. ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. I consent to release all medical information to and from my regular daytime veterinarian.Cancellation and No-Show Policy: We excel in quality care by scheduling the appropriate amount of treatment time for each patient. Your appointment is a specific time that we set aside especially for you and your companion, so it is extremely important to be timely. If you are unable to keep your appointment, YOU MUST NOTIFY THE OFFICE 48 HOURS IN ADVANCE. You will be charged a normal appointment fee for no-shows, and you may be charged a missed appointment fee for tardiness of 10 minutes or more. You will be asked to reschedule your appointment if you are 10 minutes late. Thank you for your consideration and assistance.By Clicking this box, I agree to above AUTHORIZATION and CANCELLATION* I agree Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
