» New Client Form | Sanatoga Animal Hospital

Date*

Owner Name*

Pronouns

Driver's License ID*

We also will accept any municipal or state ID.

Driver's License State & Expiration

Co-Owner Name

Children or Names of authorized Family/Friends to act as agent(s) of pet-owner(s)?

Address*

Street Address Address Line 2 City State ZIP Code

Email Address*

Cell Phone Number

Home Phone Number

Work Phone Number

Co-Owner Work Number

Co-Owner Cell Number

Emergency Contact Name*

Emergency Contact Number*

Best person to contact in case of emergency for *you*, not just your pet

Place of Employment

At what time and what phone number is best to call about your pet?*

Name of Previous Clinic

How did you hear of our hospital?

Please enter their name*

Other*

I, the above-named owner, authorize the veterinarians of Sanatoga Animal Hospital, LLC, to examine, provide vaccines & parasite control for, precribe medications for, and treat my pet(s), as needed.

I understand that in order to prevent the spread of infectious diseases and parasites, all hospitalized and boarded patients must be current on physical exam, vaccines, lab tests, and be determined free of all internal & external parasites. I understand that in compliance with PA state law and risk management guidelines, all pharmacy items including drugs, fluid therapy, nutritional & food products are non-returnable.

I understand that this policy is to protect my pet from receiving items that may have been tampered with or improperly used. I give you permission to take and use photographs of my pet(s) in print or digital media including but not limited to: Facebook, Instagram, Twitter, and sanatogavet.com.

I understand that services are provided by appointment only and I acknowledge that missed/cancelled appointments would accrue fees according to the scheduling policy.

I authorize this office to remind me of the vaccines due for my pet(s) through mail, phone call, text or email, as a courtesy.

I understand that I may request a verbal or written estimate from the doctor prior to the administration of all services.

I agree to take financial responsibility and to pay in full, at time of visit, for all charges due for services & procedures rendered.

I understand that a late charge, at a periodic rate of 1.5 % per month, APR 18%, minimum charge $1.00, is applied to all accounts deemed unpaid by the end of the calendar month.

I understand that on the occasion of a return check, a fee of $35 would be added to my account. I acknowledge that if my account is sent to an outside collection agency, a surcharge of $30 will be applied to my account.

I agree to reimburse you, Sanatoga Animal Hospital, the fees of any collection agency, which may be based on a percentage at a maximum of 33% of the debt, all costs, and expenses, including reasonable attorney fees SAH may incur in such debt collection efforts

Preferred Method Of Payment*

Signature*

First Pet

Pet Information*

Name	Species	Age / D.O.B.	Color	Sex	Spayed or Neutered?

Date of Vaccinations

DA2P	Bordetella	FVRCP	Rabies	Lyme Disease	Feline Leukemia Test	Feline Leukemia Vaccine	Other

Additional Dates

Heartworm Test	Heartworm Prevention	Fecal Exam	Dentistry	Prior Illness	Prior Surgery

Second Pet

Pet Information

Name	Species	Age / D.O.B.	Color	Sex	Spayed or Neutered?

Date of Vaccinations

DA2P	Bordetella	FVRCP	Rabies	Lyme Disease	Feline Leukemia Test	Feline Leukemia Vaccine	Other

Additional Dates

Heartworm Test	Heartworm Prevention	Fecal Exam	Dentistry	Prior Illness	Prior Surgery

Third Pet

Pet Information

Name	Species	Age / D.O.B.	Color	Sex	Spayed or Neutered?

Date of Vaccinations

DA2P	Bordetella	FVRCP	Rabies	Lyme Disease	Feline Leukemia Test	Feline Leukemia Vaccine	Other

Additional Dates

Heartworm Test	Heartworm Prevention	Fecal Exam	Dentistry	Prior Illness	Prior Surgery

Signature*

File Upload

Drop files here or

Max. file size: 256 MB.

If you prefer not to attach your pet(s)' medical documents to this form, please send or bring all existing medical records from elsewhere via email, fax (6103262015), or photocopies brought with you to the appointment. If you haven't yet scheduled an appointment at our office please call 610-326-6346. If our office isn't open when you call, please leave us a voicemail or complete the appointment request form found here. After completing this form, don't forget to also complete the Scheduling Policy Form/Missed Appointment Policy Form found here

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First Pet

Second Pet

Third Pet