Your Information

Name(Required)

First Last

Primary Phone(Required)

Please provide the best number to reach you on the phone.

Secondary Phone

Work phone, landline, etc.

Email

Address(Required)

Street Address Address Line 2 City State ZIP Code

Your Date of Birth(Required)

Driver's License, Military ID, or State ID Number(Required)

Does your pet have a co-owner?(Required)

Yes

No

Co-owner's Name(Required)

First Last

Co-owner's Primary Phone(Required)

Pet Information

Pet’s Name	Species	Breed & Color	Actions

There are no Pets.

Pet's General Practice Veterinarian(Required)

Reasons for Today's Visit(Required)

Authorizations

CPR Consent(Required)

Yes, I approve AEC to administer CPR as needed

No, I decline CPR services (DNR — Do Not Resuscitate)

In the event your pet goes into cardiac or respiratory arrest while at AEC, do you authorize Cardiopulmonary Resuscitation (CPR) to be initiated? *CPR fee: $350

Signature(Required)

New Patient Form

Your Information

Pet Information

Authorizations