Owner Information

Authorized contacts will have permission to make medical decisions and have full access to the account.

Authorized Contact #1

Name(Required)

First Last

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number(Required)

Email(Required)

Enter Email Confirm Email

Authorized Contact #2

Name

First Last

Mailing Address

Street Address Address Line 2 City State ZIP Code

Phone Number

Enter Email Confirm Email

Emergency Contact (In the event that the primary and secondary contacts cannot be reached)

Name

First Last

Phone

**Is this contact authorized to make medical decisions and have full access to this account?

Yes

Patient Information

Pet #1

Name(Required)

Age(Required)

Species(Required)

Breed/Color(Required)

Sex(Required)

Male

Male Neutered

Female

Female Spayed

Pet #2

Name

Age

Species

Breed/Color

Sex

Male

Male Neutered

Female

Female Spayed

Referral Information

How did you hear about us?

If referred by a client, please provide name and phone

Financial Policy Statement

Fort Thomas Animal Hospital requires payment in full at the end of your pet's examination or services.

We accept the following payment methods:

Cash
Major credit cards including: Visa®, MasterCard®, American Express® or Discover Card®
Care Credit® Healthcare Credit Card(For more information ask our Customer care representatives, who can assist with the application process)
Check

Please provide information below regarding the party who is financially responsible for the pet(s) on this account:

Name(Required)

First Last

Phone(Required)

Email(Required)

By signing below, you certify that the information above is correct, and that you understand and agree with the policy listed above

Signature(Required)

Date(Required)

Record Release Authorization

Client Name

First Last

Pet's Name(s)

I, the owner or agent of the pet(s) listed above, authorize the release of my pet’s medical records to the following:

Veterinary Offices
Boarding Facilities
Daycare Facilities
Grooming Facilities
Shelters and Rescues (In the event I am applying to adopt or foster a pet)

I understand that I may revoke this authorization at any time by contacting Fort Thomas Animal Hospital.

Signature of Owner(Required)

Date(Required)

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New Client Form

Owner Information

Patient Information

Referral Information

Financial Policy Statement

Record Release Authorization

Expert Veterinary Care in Fort Thomas, KY