3604 Rte 378, Bethlehem, PA 18015
nsah@northsauconanimalhospital.com
610‑867‑0800
Our Practice & Staff
Services
Acupuncture
Wellness Care
Dentistry & Dental X-Ray
Puppy and Kitten Care
General Surgery
Laboratory Tests
Digital Radiology & Ultrasound Imaging
Nutritional Counseling
Senior Care
Resources
Testimonials
Online Store
CONTACT US
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New Client and Pet Information
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New Client and Pet Information
New Client and Pet Information
Date
*
Pet Owner's Name
*
Is pet owner over 18 years old?
*
Yes
No
Spouse or Partner's Name
Address
*
City
*
State
*
Alabama
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Zip
*
Phone Number (home)
*
Phone Number (mobile)
Phone Number (work)
Email Address
*
All fees are due when services are rendered. Please indicate your choice of payment method.
*
Cash / Check
Credit Card
Care Credit
Do you have an appointment scheduled?
*
Yes
No
Would you like use to contact you to schedule an appointment?
Yes
No
How did you hear about us?
TV
Radio
Hospital Sign
Newspaper
Internet
Drive By
Personal Recommendation
Pet Information
Pet's Name
*
Birth Date or Age
*
Sex
*
Neutered or Spayed?
*
Breed
*
Canine/Feline/Other
*
Color
*
Promo Code
Medical History/Vaccinations
(optional)
Any previous medical or surgical problems?
Yes
No
If yes, please explain
Any allergic reactions to a medication or vaccine?
Yes
No
Any current medications being taken?
Yes
No
If yes, please list:
Previous veterinarian?
From where did you obtain/purchase your pet?
Pet Store
Breeder
Stray
Rescue
For dogs, date of last:
Distemper / Parvovirus Vaccine
Rabies Vaccine
Lyme Vaccine
Bordetella Vaccine
Influenza Vaccine
Heartworm Test
Fecal Parasite Screening
For cats, date of last:
Distemper Vaccine
Rabies Vaccine
Leukemia Vaccine
Leukemia/Feline Aids Test
Fecal Parasite Screening
ID Number (for office use)