New Patient Form

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We look forward to seeing you! Please complete the form below prior to your first appointment.

Owner's Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Which number is best to reach you?(Required)

Home

Cell

Can you receive text messages?(Required)

Yes

No

Greater than 65 years of age?(Required)

Yes

No

Military / First responder?(Required)

Yes

No

Email(Required)

How would you prefer to be contacted?(Required)

Email

Phone Call

Text

Add a Co-Owner?(Required)

Yes

No

Name(Required)

First Last

Home Phone

Cell Phone

Previous Vet:

Previous Vet's Phone Number

Whom should we thank for referring you?

Pet's Name(Required)

Sex(Required)

Male

Female

Neutered/Spayed?(Required)

Yes

No

Breed(Required)

Color(Required)

Birthdate or Age(Required)

Current Medications

Please bring and give any medical records/vaccine records to the receptionists to make copies.

Diet(Required)

Add a second pet?(Required)

Yes

No

Hidden

Section Break

Pet's Name(Required)

Sex(Required)

Male

Female

Neutered/Spayed?(Required)

Yes

No

Breed(Required)

Color(Required)

Birthdate or Age(Required)

Current Medications

Please bring and give any medical records/vaccine records to the receptionists to make copies.

Diet(Required)

Add a third pet?(Required)

Yes

No

Hidden

Section Break

Pet's Name(Required)

Sex(Required)

Male

Female

Neutered/Spayed?(Required)

Yes

No

Breed(Required)

Color(Required)

Birthdate or Age(Required)

Current Medications

Please bring and give any medical records/vaccine records to the receptionists to make copies.

Diet(Required)

Hidden

Section Break

I hereby authorize the veterinarian to examine, prescribe for, or treat the pet described above. I assume responsibility for all charges incurred in the care of this animal. I also understand that those charges will be paid in full at the time of release and that a deposit may be required for surgical treatment. Unpaid balances are subject to collection costs including late payment fees, court costs and attorney’s fees.(Required)

I have read and agree

Checks under $200 will be accepted. We charge a $25 fee for returned checks. Please initial that you read and understand the previous stated policy.(Required)

Please initial

Four Paws at Fulshear does not work directly with outside pharmacies. Written prescriptions are available upon request that can be mailed directly to an outside pharmacy. Please initial that you read and understand the previous stated policy.(Required)

Please initial

Any small pet that is without a leash or not in a carrier will be provided with a cardboard carrier at the owners expense of $15.00. Please initial that you read and understand the previous stated policy.(Required)

Please initial

Your pet will be checked for fleas during his/her exam. If fleas are found, a Capstar will be administered to your pet at your expense. Capstar is a fast-acting flea treatment for use in dogs and cats that starts killing fleas in only 30 minutes. Please initial that you read and understand the previous stated policy.(Required)

Please initial

If there is a no show / no call appointment, we will require a deposit for future visits. Please initial that you read and understand the previous stated policy.(Required)

Please initial

Do we have your permission to share your pet’s image and story on our social media, website, and other forms of related media? Your name and personal information will never be shared.(Required)

Yes

No

I authorize my emergency contact (other than myself or co-owner) to pursue treatment if I am unavailable. Your emergency contact must be an adult over the age of 18.(Required)

I have read and agree

Emergency Contact(Required)

First Last

Phone(Required)

Digital Signature of Owner(Required)

Date(Required)

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Comments

This field is for validation purposes and should be left unchanged.