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Home
About the Hospital
Careers
AAHA-Accredited Practice
Our Services
Physical Examinations and Vaccines
Surgery
In-House Diagnostics
Therapeutic Laser Treatments
Canine Reproduction
Dentistry Procedures
Meet the Hospital Team
Resources
FAQs
Hospital New Patient Form
Health Certificate Information
Canine Reproduction
Online Pharmacy
Contact Us
Make an Appointment
(480) 448-9060
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Hospital New Patient Form
Hospital New Patient Form
New Patient Form – One Per Pet
Name
(Required)
First
Last
Email
(Required)
Spouse/Partner/Co-owner:
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
CĂ´te d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
RĂ©union
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
TĂĽrkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ă…land Islands
Country
Primary Phone
(Required)
Secondary Phone
How Did You Hear About Us?
Sign / Location
Applewood Pet Resort
Internet (Tell us where below)
Other (Describe below)
Personal Referral (Tell Us Who We Can Thank Below)
Referral Name
Other
We occasionally like to share patient photos on social media. Do you give us permission to use your pet’s photos?
Yes, my pet was born to be a STAR!
No, my pet is shy
Patient Information
Pet's Name:
Pet Type:
Dog
Cat
Other (If other, please describe below)
If other:
Pet's Breed:
Pet Gender:
Male
Female
Spayed/Neutered?
Yes
No
Date of Birth:(If unknown, approximate age)
Color:
Would you like us to obtain your pet’s medical record from another veterinarian to update our records?
Yes
No
If yes, doctor/hospital name:
Do you already have an appointment scheduled with us?
Yes
No
If yes, when?
Financial, Medical information and Liability Release
I understand every effort will be made to achieve a successful outcome and to provide for all possible safety issues in hospital care and handling. I hereby authorize Applewood Animal Hospital to receive, prescribe for, treat and/or perform surgery upon the pet(s) listed herein and additional pets I present. I understand that no guarantees have been made as to the results of medical and/or surgical treatment. I agree to release Applewood Animal Hospital and its staff from any liability resulting from the treatment, surgery and/or hospitalization of my animal(s). I certify that I am over 18 years of age and am the owner or owner’s authorized agent of animals identified on the Patient Information Form. I agree to pay fees for services rendered at the time the pet is discharged from the hospital or as agreed prior to treatment. I assume full responsibility for all charges incurred in the treatment of my pets. I agree that in the event that any unpaid balance is referred to a collection agency, I will be responsible for all collection fees, legal fees and court costs and my owed balance may substantially increase.
I Agree
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