Please fill out our New Patient Form using one of the options below if your pet is a new patient at Crossroads Veterinary Hospital.

Request Appointment

Option 1

Complete Online

Complete and submit the online form below.

Option 2

Print & Complete

Bring the completed form with you to our hospital.

Download Form

Option 3

Complete on Arrival

If you prefer, fill out the form when you get to our hospital.

New Patient Form

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

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

Yes

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 Crossroads Veterinary Hospital to release patient information to the primary care hospital or veterinarian.

Primary Care Facility

Primary Care Veterinarian(s)

By submitting this form, I hereby authorize Crossroads Veterinary Hospital 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 Crossroads Veterinary Hospital.

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Patients

Patients Information
Pet Insurance
New Patient Form
Veterinary Blog
Fear Free
Financing Options

AAHA Accredited Fear Free Patient Account Login Log in to your pet's patient account to book an appointment, refill a prescription, or access your pet's medical records.

Happy Tails from Clients

"Dr. Martin is really great. I’ve never had bad service here. Everyone loves animals so much and they take great care of both my dog and cat! Dr. Martin spent 15 minutes on the phone talking through everything we needed to do to get my puppy up to the best health."
Kate N.

New Patient Form

Option 1

Complete Online

Option 2

Print & Complete

Option 3

Complete on Arrival

New Patient Form

Owner Information

Emergency Contact

Patient Information

Primary Veterinarian Information

We Are Always Accepting New Patients