New Patient Form – AcupunctureOwner's Name*Driver's License/ Social Security NumberPartner/Spouse's NameAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone Number*Phone Type* Home Cell Work Additional Phone NumberPhone Type Cell Phone Home Phone Work Phone Email* Would you like to receive reminders via email?* Yes No If yes, reminder cards will not be mailed.Are you eligible for a senior citizens discount (62 yrs)?* Yes No Pet InformationPet's Name*Species*Breed*Age/Birthdate*Gender*Spayed/Neutered?* Yes No Unknown Color / Markings*Medical RecordsDo you understand that you are responsible for having your pet’s medical records emailed to us at ParkStreetVet@yahoo.com prior to scheduling an appointment?* Yes May we contact your Primary Veterinarian with information and updates related to your pets acupuncture treatment?* Yes No Presenting complaint/major reasons for acupuncture*When did this all start?Please list all current medications, duration of treatment & dose*Any previous medical issues or history not listed aboveName and phone number (if known) of primary veterinary practiceWould you like us to contact you to schedule an appointment?* Yes No I already have an appointment scheduled Please list the reason(s) for your pet's appointmentSpecial requests or conditions?How did you hear of us? Phone book Internet Newspaper Existing client/friend Other I was referred by:Photo Release: I grant Park Street Veterinary Clinic, it’s representatives and employees the right to take and/or use photographs of my pet(s). I authorize Park Street Veterinary Clinic, it’s assignees and transferees to copyright, use and publish the same print and/or electronically without compensation. I agree that Park Street Veterinary Clinic may use such photographs of me and/or my pet(s) with or without my name and/or my pet(s) name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising and web content.I have read this statement and* I grant permission to take/use photos as described above I do not grant permission to take/use photos Payment Policy: I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Park Street Veterinary Clinic and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% APR. Any balance that I leave unpaid will be forwarded to Park Street Veterinary Clinic's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.I have read this statement and* I Agree CAPTCHA