New Patient Form

If your pet is a new patient at our hospital, please fill out our New Patient Form using one of the options below.

Once you have completed the New Patient Form, please also complete the Specialty Form for the veterinary specialist your pet has been referred to.

Specialty Forms

OPTION 1
Complete Online

Complete and submit the form below.

OPTION 2
Print & Complete

Bring the completed form with you.

Download Form

OPTION 3
Complete on Arrival

If you prefer, you can complete the form when you get to our hospital.

New Patient Form

Please provide us with the following information.

Client Information

Owner First Name *

Owner Last Name *

Co-Owner / Spouse Name

Home Address *

City *

State *

Zip *

Email Address *

Call 1st Phone Number *

Call 1st Contact

Secondary Phone Number

Secondary Contact

Date of Birth *

Note: At your first appointment at our hospital, we may ask to collect your driver's license and social security number for payment collection purposes. We will also require a photo copy of your license.

Patient Information

Patient Name *

Type of Animal *

Breed *

Sex *

Birth Date / Age *

Color

Are vaccinations current? *

Reason for Referral (Primary Complaint) *

Please list any of your pet's drug allergies or special problems that we should know about. *

Who is your primary veterinarian?

Have you heard about our hospital prior to this referral? *

If yes, how did you hear about us?

Did you bring x-rays, lab work or medical records from your veterinarian? *

Photography Release Form

Memphis Veterinary Specialists & Emergency uses public social media forms, as well as other digital and print media to promote pet health, educate the community about our services, and share the faces and stories of our beloved patients.

Do you consent to having your pet's photo(s), first name, and medical information shared on our public social media forums, digital media and print media for those purposes?

Yes

RDVM Name

Clinic Name

Payment Information

I understand I am financially responsible to Memphis Veterinary Specialists & Emergency for all charges. I understand that payment is due in full at the time services are rendered. I agree to pay all interest, collection, legal, attorney or court fees in the event it becomes necessary to pursue the account for collection. If your account is placed in a collection agency, a collection-fee of up to 33.3% may be added to your account and shall become a part of the Total Amount Due. We accept cash, checks, major credit cards and Care Credit. TeleCheck authorizes all checks. When you provide a check as payment, your authorize us to use information from your check to process a one-time payment Electronic Funds Transfer (EFT), a draft drawn from your account or to process the payment as a check transaction. Unless specifically requested, all pets needed emergency care while staying in our hospital will be treated until the owner / agent can be contacted.

By submitting this form, I agree to the above.

Spam Blocker

From Happy Pet Owners

"Very professional staff. Very competent and to the point when it comes to how you need to continue care once you get home.”
Wanda S.

New Patient Form

OPTION 1Complete Online

OPTION 2Print & Complete

OPTION 3Complete on Arrival

New Patient Form

Client Information

Patient Information

Photography Release Form

Payment Information

From Happy Pet Owners

OPTION 1
Complete Online

OPTION 2
Print & Complete

OPTION 3
Complete on Arrival