Bergen Veterinary Hospital - New Patient Form

Bergen Veterinary Hospital Client & Patient Registration Welcome to Bergen Veterinary Hospital - your other family doctor and thank you for choosing us for your pet's care. Please take a moment to COMPLETE this form accurately. A VALID DRIVER'S LICENSE/PHOTO STATE ID IS REQUIRED FOR IDENTIFICATION (only PRIMARY and/or SECONDARY OWNERS Thank You. If a section does NOT apply to you, Please type "N/A" if Not Applicable to continue to the next section.

PRIMARY Owner's Name:(Required)

First Last

Secondary Authorized Person Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

PRIMARY Phone Number(Required)

SECONDARY Phone Number(Required)

PRIMARY Email Address(Required)

How did you hear about our hospital?

Individual (someone we may thank)

Online Search Engine (Google, Yelp, etc)

Advertisement (Flyers, Postings, Coupons)

Hospital Sign

Other

PHOTOS: I hereby grant Bergen Veterinary Hospital permission to use any photographs taken of myself or my pet(s), in any and all of its publications, including website entries, without payment or any other consideration. I understand and agree that these materials will become the property of Bergen Animal Hospital and will not be returned. l hereby authorize Bergen Animal Hospital to edit, alter, copy, exhibit, publish or distribute this photo for purposes of publicizing their programs or for any other lawful purpose. In addition, I waive any right to royalties or other compensation arising or related to the use of the photograph. I hereby release Bergen Animal Hospital from all claims, demands, and causes to action which I, my heirs, representatives, executors, administrators, or any other persons acting on behalf of my estate have or may have by reason of this authorization(Required)

I AGREE to have my pet(s) photo taken

I DECLINE to having my pet(s) photo taken

I UNDERSTAND AND AGREE that payment is due IN FULL at any time product(s) or service(s) are provided for my pet and any pet brought into the hospital by me. I understand that NO billing or payment plan options (other than Scratch Pay or Care Credit) will be offered by Bergen Veterinary Hospital. If a balance is outstanding against hospital policy, I agree and understand that I WILL BE charged a Finance and End of the Month Billing charges for ALL outstanding amounts until the bill is PAID IN FULL. Estimates are provided upon request.

I further agree that I have signed this document of my own free will and that this agreement is subject to both federal and state laws. Furthermore, I certify that the information provided on this form is accurate and complete to the best of my knowledge.

Signature(Required)

Date(Required)

Owners Responsible Party PRINTED(Required)

Date(Required)

A valid Driver's License -OR- Valid Photo State ID is required for IDENTIFICATION (only PNMARY and/or SECONDARY OWNERS)(Required)

Max. file size: 8 MB.

Please provide your pet(s) info on the next page

TELL US ABOUT YOUR PET

Pet's Name

Pet's Species

Pet's Breed

Pet's Description (Fur Color/ Unique Markings)

Pet's Age -OR- Date of Birth (MM/DD/YY)(Required)

Pets Age

Date of Birth

Gender/Sterilization Status(Required)

Male

Neutered Male

Female

Spayed Female

Pet's Food Diet and/or Treats

Pet's Daily Medication(s)/ Vitamins)

Pet's Microchip # (if applicable)

Vaccines Received: (List vaccines and dates below)(Required)

Vaccines Name

Date vaccine was received

Diagnostic Testing: (Indicate all bloodwork and fecal tests performed, including dates)(Required)

Name of Test

Date test was performed

Medical History/ Prior Illness/ Surgery (Please type "N/A" if Not Applicable)

Please upload your previous medical records here

Max. file size: 8 MB.

If you cannot upload your medical records in the prior section, kindly submit any prior medical records via email to info@bergenvet.com or by fax to (201) 353-3400

Records Release Form

Bergen Veterinary Hospital 1154 Teaneck Road - Teaneck, NJ 07666

P: 201-837-3470 F: 201-353-3400

Veterinary Medical Records Release Form

PRIMARYAUTHORIZED PERSON NAME

I, the undersigned do hereby grant my permission for the release of any or all the information contained in the medical records of those pets listed below to the following person or veterinary practice:

Pet Name(s) For Release of Medical Records

Records to be released (check all that applies)

EMR (Entire Medical Record)

Radiographs

All Doctors Notes

Vaccines Only

Release Records to: (please put your personal email here)

Fax

Date Records needed by

Reason for Request of Records

*** Please be advised that this form is required to be completed annually AND/OR the information to release records to is DIFFERENT than indicated on form.

PRIMARYAUTHORIZED PERSON SIGNATURE

DATE

PRIMARYAUTHORIZED PERSON PRINTED

DATE