Cat Clinic and Hospital

5170 Liberty Avenue, Pittsburgh, PA 15224

Tel: (412) 681-1122

New Patient Form

Please call for an appointment before filling out and submitting this form: (412) 681-1122

Owner Information

Name *

Street Address *

City, State, Zipcode *

Contact Phone Number *

Is This a Cell Phone?

Yes

If this is a cell phone, do you agree to receiving reminders
for appointments/vaccinations at this number?

Yes

No

Email Address

Do you agree to receive reminders at this email?

Yes

No

If there is another person responsible for the care of this cat, and with whom we may discuss this cat’s medical condition and needs, please fill out the following for that person.

Name

Relationship

Contact Phone Number

Is This a Cell Phone?

Yes

Patient Information

Cat’s Name *

Color *

Breed

Select Those That Apply

Female	Spayed
Male	Neutered

Approximate Birth Date

Adopted From

Year of Adoption

Diet

Wet

Dry

Food Brands

Patient Medical History

Provide Dates for the following

Last Rabies vaccination

Last FVRCP vaccination

Last Feline Leukemia vaccination

Last Leukemia/FIV Test

Results

Positive	Negative
Other

Last Flea Preventative

List any serious illnesses or surgeries in the past

Any allergic reactions to vaccines or medications

List any other known allergies

Which, if any, medications is your cat currently taking?

Previous veterinary hospital name

How many pets in your household?

Cats

Dogs

Other

Do you give the Cat Clinic and Hospital permission to take
pictures of your cat for marketing and promotional purposes,
identifying your cat by first name only?

Yes

No

CONSENT TO TREAT AND FINANCIAL RESPONSIBILITY

I HEREBY GRANT PERMISSION TO the Cat Clinic and Hospital staff to examine and treat my cat. I assume responsibility for the charges incurred in the treatment/care of my cat as discussed with the veterinarian and/or veterinary technicians. Full payment is due at the time of your cat’s evaluation, treatment, and/or discharge. We accept cash, Visa and Mastercard. Checks are accepted with prior approval by management.

Owner / Guardian's Name

I Consent

Yes

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Vomiting	Change in appetite
Constipation	Difficulty urinating
Sneezing	Eye discharge
Itching	Skin growth
Changes in behavior	Diarrhea
Change in weight	Frequent urination
Lethargy	Coughing
Vision problems	Hair loss
Lump or mass
Other