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Wellness Plans
About Us
Contact Us
- Appointment Request
Patient Center

Services
Wellness Plans
About Us
Contact Us
- Appointment Request
Patient Center

(714) 771-3261

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New Client Form

New Client Form

Download New Client Form

HEALTHY PET HOSPITAL

Client Information

*Thank you for allowing us to care for your pet. Please help us better meet your needs by taking a few moments to fill out this information sheet.

Owner’s Last Name:*

First Name:*

Co-Owner (if applicable):*

Address:*

City:*

Zip:*

Phone #: *

Cell Phone #: *

Email address *

Owner's Date of Birth *

In Case of EMERGENCY, Call: *

Phone #: *

Contact information for previous medical records:*

How did you hear about us? *

**************************************************************************************************

*We will gladly prepare a written estimate if you so desire. Professional fees are due at time services are rendered.

*To help prevent the spread of infectious diseases, ALL elective surgery patients, hospitalized patients, and boarded animals must be current on ALL core vaccinations. You must provide adequate printed vaccination history at check-in. DUE TO STATE LAW AND INSURANCE REQUIREMENTS, ALL DOGS & CATS MUST BE CURRENT ON RABIES VACCINATION. Vaccination can be updated at the time of your appointment if it is not current.

By signing below, I am verifying that all the above information is correct. I understand that all charges are due when services are rendered, and I accept full responsibility for the charges incurred during every visit to Healthy Pet Hospital. Furthermore, I hereby agree to pay all costs of collection or legal fees should such action be necessary due to non-payment.

Signature:*

HEALTHY PET HOSPITAL

Patient Information

Please fill out all your Pets!

Pet 1:

Name OR Animal ID Number:*

Species (circle one):

Cat Dog Other

Other (Species) :

Breed:*

Color:*

Birth Date/Age:*

Behavioral problems:

Sex (circle one):

Male Female – Spayed Neutered

Does your pet have any known allergies or vaccine reactions?

Yes No

Pet Microchipped:

Yes No

******************************************************************************************

Pet 2:

Name OR Animal ID Number:

Species (circle one):

Cat Dog Other

Other (Species):

Breed:

Color:

Birth Date/Age:

Behavioral problems:

Sex (circle one):

Male Female – Spayed Neutered

Does your pet have any known allergies or vaccine reactions?

Yes No

Pet Microchipped:

Yes No

******************************************************************************************

Pet 3:

Name OR Animal ID Number:

Species (circle one):

Cat Dog Other

Other (Species):

Breed:

Color:

Birth Date/Age:

Behavioral problems:

Sex (circle one):

Male Female – Spayed Neutered

Does your pet have any known allergies or vaccine reactions?

Yes No

Pet Microchipped:

Yes No

******************************************************************************************

Pet 4:

Name OR Animal ID Number:

Species (circle one):

Cat Dog Other

Other (Species):

Breed:

Color:

Birth Date/Age:

Behavioral problems:

Sex (circle one):

Male Female – Spayed Neutered

Does your pet have any known allergies or vaccine reactions?

Yes No

Pet Microchipped:

Yes No

******************************************************************************************

Thank You

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Office Hours

Our Regular Schedule

Monday

9:00 am - 6:00 pm

Tuesday

9:00 am - 6:00 pm

Wednesday

9:00 am - 6:00 pm

Thursday

9:00 am - 6:00 pm

Friday

9:00 am - 6:00 pm

Saturday

9:00 am - 5:00 pm

Sunday

Closed

Our Location

Find us on the map

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Healthy Pet Hospital

Address

3411 E Chapman Ave
Orange, CA 92869

Contact Information (714) 771-3261

Contact Us

Name*

Email *

Phone *

Comments

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(714) 771-3261

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