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.

OPTION 1
COMPLETE ONLINE

Complete and submit the online form below.

OPTION 2
PRINT & COMPLETE

Bring the completed form with with you.

Download PDF

OPTION 3
COMPLETE AT OUR HOSPITAL

If you prefer or if time does not allow, you can complete the form when you get to our hospital.

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.

Spam Blocker

New Patient Form

Please Note

OPTION 1COMPLETE ONLINE

OPTION 2PRINT & COMPLETE

OPTION 3COMPLETE AT OUR HOSPITAL

New Patient Form

Client Information

Patient Information

Payment Information

Comments About Our Care

OPTION 1
COMPLETE ONLINE

OPTION 2
PRINT & COMPLETE

OPTION 3
COMPLETE AT OUR HOSPITAL