New Patient Registration This lets us record our pet and owners into our management software so that we can effectively and efficiently provide the service you deserve! Step 1 of 3 33% Owner InformationName* First Last Members of the family that are permitted to bring your pet(s) for treatment. Must be at least 18 years old.Address* 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 Home PhoneWork PhoneCell Phone #1Cell Phone #2Email* Email Address Confirm Email How Did You First Become Aware Of Our Clinic?*Choose One...Personal RecommendationAnasazi WebsiteDexonlineYellow PagesPrevious ClientEmergency Hospital or other VetAnimal Care & ControlDrove ByPet StoreYelpOtherWhom Should We Thank? Please Specify Subscribe Please subscribe me to the FREE Pet Living & Wellness Newsletter Interested In Dogs Cats Horses Birds Reptiles Rodents Dr/Member Announcements Select Topics of InterestThe policy of Anasazi Animal Clinic is to provide an estimate of charges for any case where in-hospital treatment, surgery or hospitalization will be provided. Please feel free to discuss any fees prior to services rendered. Pet InformationPet's Name* First Last Species*DogCatOtherPlease Specify Species* Breed* Description (color or markings) Age / Date of Birth* This Pet's Sex*Choose One...MaleFemaleUnsureIs This Pet Spayed/Neutered?*Choose One...YesNoUnsureDiet (kind of pet food) Vaccinations Your Pet Needs DA2PPV (distemper/parvovirus - dog) FVRCP (infectious diseases - cat) Felv (feline Leukemia) Feline Leukemia Test Rabies (dog/cat) Other Vaccines Other Vaccinations Is your pet's rabies vaccine current? Yes No Other should only be used in the case that the animal has been rescued or found, etc. If other, please specify the situation.Current Medications/Dosages Known Drug Allergies Other Major Medical Issues Visit InformationAppointment Date* MM slash DD slash YYYY Appointment Time* : Hours Minutes AM PM Previous Veterinarian* Reason for Visit* Duration of Problem* CONSENTS: I authorize and direct the veterinarians at Anasazi Animal Clinic to examine, diagnose, prescribe, perform therapeutic procedures, and/or surgery that their judgment may dictate to be advisable for the patient’s well being. No warranty or guarantee has been made as to the result or cure. ALL FEES ARE REQUIRED TO BE PAID IN FULL UPON COMPLETION OF THE VISIT. We accept cash, all major credit cards, and Synchrony CareCredit with the required identification. A deposit is required at the time of admission and the balance paid in full at discharge. If you have any questions about the fees or the financial policy, please alert a staff member before services are performed. Accounts not paid within 30 days are subject to an interest finance charge. In the event any balance due is not paid as agreed, the undersigned jointly and severally agrees to pay all cost included in the unpaid balance, including a reasonable collection and /or attorneys’ fees.* I have read and understand the financial policyI hereby irrevocably consent to the use of any images of my pet, taken by Anasazi Animal Clinic, in any and all marketing or teaching materials.* Yes No When drugs are FDA-approved for use in one species but are administered to species other than those for which they have been approved and labeled, the terminology is that the drugs are being used in an “extra-label” manner. Extra-label use does NOT include the use of experimental drugs or drugs manufactured in foreign countries that have not been approved by the FDA. Because few drugs are labeled for use in small animals, most drugs administered by small animal or exotic animal veterinarians, including antibiotics, anesthetic agents, and other medications, are routinely used in an extra-label manner. This is within the standard of care, but good medical practice requires that owners be advised when drugs are being used in an extra-label manner.* I authorize the staff at this veterinary practice to administer and prescribe extra-label drugs for my pet. I understand that any drug, including those that are used in an extra-label manner, can produce undesirable side effects. Thus, I acknowledge that it is my responsibility to administer prescribed medications for my pet as directed and to notify my veterinarian of any apparent side effects or complications.Signature of Responsible Party* First Last Must be over 18 years of age.Today's Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
