Owner Information

Owner First Name *

Owner Last Name *

Secondary Owner / Spouse's Name

Email *

Primary Phone *

Mobile Phone

Work Phone

Address *

City *

State *

Zip Code *

How did you hear about us? *

Primary Care Veterinarian

Internet

Friend / Family

Community Event

Signage

Printed Publication

Radio

Other

If you have another Primary Vet, please list their name/animal hospital here:

Would you like to join our emailing list? *

Yes

No

Emergency Contact

Primary Emergency Contact Name *

Primary Emergency Contact Phone *

Secondary Emergency Contact Name

Secondary Emergency Contact Phone

Do you authorize your emergency contact(s) to make urgent treatment decisions if you are unreachable? *

Yes

No

Do you authorize your emergency contact(s) to receive patient information in addition to your primary care veterinarians? *

Yes

No

Pet Information

1st Pet's Name *

Birth Date / Age *

Species *

Breed / Other Species *

Color

Vaccination Status *

Gender *

Spayed or Neutered? *

Presenting problem, special needs, concerns *

2nd Pet's Name *

Birth Date / Age *

Species *

Breed / Other Species *

Color *

Vaccination Status *

Gender *

Spayed or Neutered *

Presenting problem, special needs, concerns *

Primary Veterinarian Information

Please fill this section in if we are not your primary care veterinary hospital. By listing your primary care veterinarian, you are authorizing Wachusett Animal Hospital & Pet Retreat to release patient information to the primary care hospital or veterinarian.

Primary Care Facility

Primary Care Veterinarian(s)

By submitting this form, I hereby authorize Wachusett Animal Hospital & Pet Retreat to render medical care for my pet(s) as deemed necessary by the veterinarian. I understand that no guarantee can be given to the outcome of treatments and take it as my responsibility to comprehend any risks involved. I agree to pay for the cost of all services to which I consent to by written or verbal estimate. I understand that a deposit is required before diagnostics and treatments can be initiated and that payment in full is required prior to discharge of patient from Wachusett Animal Hospital & Pet Retreat.

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New Patient Form

Option 1

Complete Online

Option 2

Print & Complete

Option 3

Complete on Arrival

Owner Information

Emergency Contact

Pet Information

Primary Veterinarian Information

Welcoming Cats & Dogs to Our Animal Hospital