New Patients Form | Animal Emergency Hospital | Memphis

If your pet is a new patient at Animal Emergency Center in Memphis, please fill out our New Patient Form using one of the options below.

Please Note

Submitting the online New Patient Form does not notify us that you are on your way. If possible, please call us ahead of time.
If you are experiencing an emergency during regular business hours, contact your primary care veterinarian.

New Patient Form

Client Information

Owner First Name

Owner Last Name

Co-Owner / Spouse Name

Home Address

Apt, Suite, etc.

City

State

Zip

Email Address

Primary Phone Number

Secondary Phone Number

Co-Owner Phone Number

Date of Birth

Employer

Occupation

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 may 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 Visit (Primary Complaint)

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

Who is your primary care veterinarian / veterinary clinic?

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?

Payment Information

I understand I am financially responsible to Animal Emergency Center 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 CareCredit. 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.

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New Patient Form

Please Note

New Patient Form

Client Information

Patient Information

Payment Information

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