Owner Information

Owner First Name *

Owner Last Name *

Secondary Owner / Authorized Agent Name

Email *

Primary Phone *

Mobile Phone

Work Phone

Address *

City *

State *

Zip Code *

Employer *

Occupation *

Date of Birth *

How did you hear about us? *

Primary Care Veterinarian

Internet

Friend / Family

Community Event

Signage

Printed Publication

Radio

Other

Emergency Contact

Primary Emergency Contact Name *

Primary Emergency Contact Phone *

Secondary Emergency Contact Name

Secondary Emergency Contact Phone

Do you authorize your emergency contact(s) to make urgent treatment decisions if you are unreachable? *

Yes

No

Do you authorize your emergency contact(s) to receive patient information in addition to your primary care veterinarians? *

Yes

No

Patient Information

Pet Name *

Birth Date / Age *

Species *

Breed / Other Species *

Color

Vaccination Status *

Gender *

Spayed or Neutered? *

Presenting problem, special needs, concerns *

Primary Veterinarian Information

Please fill this section in if we are not your primary care veterinary hospital. By listing your primary care veterinarian, you are authorizing Animal Hospital of Redondo Beach to release patient information to the primary care hospital or veterinarian.

Primary Care Facility

Primary Care Veterinarian(s)

Cancellation Policy

In order to respect our client’s and staff's time for appointments, all new clients will be charged a non-refundable initial exam in order to secure an appointment. This will applied to the examination upon check-in of the appointment.

For all clients, failure to cancel an appointment without giving us 24 hours notice or no-showing for your appointment will result in being charged for the missed appointment.

For your convenience, we will call to remind you of your appointment 2 days in advance. If you are unable to keep your appointment please call our office at least 24 hours prior. This will allow us to have appointment slots available for our patients with emergencies.

I have read and fully understand the cancellation/no show policy. *

Yes

No

By submitting this form, I hereby authorize Animal Hospital of Redondo Beach to render medical care for my pet(s) as deemed necessary by the veterinarian. I understand that no guarantee can be given to the outcome of treatments and take it as my responsibility to comprehend any risks involved. I agree to pay for the cost of all services to which I consent to by written or verbal estimate. I understand that a deposit is required before diagnostics and treatments can be initiated and that payment in full is required prior to discharge of patient from Animal Hospital of Redondo Beach.

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New Patient Form

Option 1

Complete Online

Option 2

Print & Complete

Option 3

Complete on Arrival