New Patient Form Step 1 of 2 50% Owner Name*Co-Owner NameAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email AddressHome NumberWork NumberCell Number*Co-Owner Work NumberCo-Owner Cell NumberName of Previous ClinicPhoneRecommended by Whom?Do you already have your first appointment scheduled? Yes No Best time to contact to set up new appointment? : HH MM AM PM How would you like to be contacted Email or Phone Call? Phone Email First PetSelect One:*DogCatPet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or Neutered Second PetSelect One:DogCatPet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or Neutered Third PetSelect One:DogCatPet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or Neutered I/we hereby authorize the veterinarians to examine, prescribe for, or treat my pets (s). I/we assume full responsibility for all charges incurred in the care of this/these animal(s). I/we also understand that these charges will be paid in full at the time of release and that a deposit may be required for certain surgical treatments or other procedures.I am the legal owner of the pet named above and assume responsibility for their care.*Type your name pleaseI agree situations arise when your pet's information may be needed by someone outside of Carver Lake Veterinary Center. This may include kennels, emergency clinics, or others in the community who may be in contact with your pets.*Type your name pleaseI give my permission to release any photos taken here of you or your pet for educational and/or advertising purposes.*Type your name pleaseI understand that charges incurred in the care of my pet will be paid at the time of discharge and that a deposit may be required for some treatment. In the event of default on payment, and in addition to my existing balance, I agree to pay collection costs and reasonable attorney fees totaling 40% of my current balance*Type your name pleaseType Signature*NameThis field is for validation purposes and should be left unchanged.