New Patient Form Please fill out this form and we will contact you regarding your prescription refills. REGISTRATIONOwner* First Last Date* Date Format: MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country EmployerOccupationCell Phone*Work PhoneHome PhoneEmail* Second OwnerRelationCell # (Second owner)Preferred method of contact*PhoneEmailHow did you learn about our clinic?*Drive by/signPrint AdFacebookRecommendationWebsiteInternet SearchIf recommended, by whom?Number of Pets (Dogs)Number of Pets (Cats)Number of Pets (Other - specify)CAT HEALTH HISTORYName of Cat*Breed*Color*Birthdate/Age*Sex*UndeterminedMaleNeuteredFemaleSpayedVaccination History (date and type of last vaccinations)Prior medical issues/surgeriesReason for visit*Current medications*Lifestyle*Indoor onlyIndoor/OutdoorOutdoor onlyWhat % outdoor would you consider your cat?Does your cat have insurance?*YesNoIf yes, what company provides the insurance?AUTHORIZATIONI hereby authorize the veterinarian to examine, prescribe for, and/or treat the above described pet. I assume full responsibility for all charges incurred for the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment. Accounts unpaid after 30 days are subject to a finance charge of 1.5% per mouth (annual percentage rate 18%); minimum charge of $1.00. If your account is sent to collection, you will be liable for the costs for such collection, including attorney's fees and court costs. (Signature of Owner)*Date* Date Format: MM slash DD slash YYYY Social Media Authorization - We love sharing photos of our patients! Do you authorize Mid Atlantic Cat Hospital the right to take photographs of you and/or your cat, and to copyright use and publish the same in print and/or electronically.*YesNoFEAR FREE PRE-VISIT CLIENT QUESTIONNAIREAs Fear Free certified professionals, we want to make your visit to our hospital the best it can be for you and your cat. We ask that you fill out this pre-visit questionnaire so we can take both you and your cat’s preferences for your first visit into consideration.How would you describe your cat when at the vet?*Relaxed, doesn’t seem to be mind being thereNervous, timid, or shyVery stressed or aggressive(If very stressed or aggressive, please call before your visit to discuss options to help with anxiety prior to the appointment.) Has your cat ever needed to be sedated because of their stress level when at the vet?*YesNoNot sureHas your cat ever been prescribed or recommended a medication for stress or anxiety to help with a visit to the vet?*YesNoNot sureIf yes, do you know the name of the medication and did it help?UntitledWe do ask that all cats arrive in carriers. Do you find it difficult to get your cat into the carrier?*YesNoSometimes (If yes, please call before your visit to discuss options to help with travel to the hospital.) Does your cat experience any vomiting, drooling, or defecation while in the car or carrier?*YesNoSometimesAs part of our Fear Free pledge, we won't force your cat to do anything he or she doesn't want to do. This sometimes means we prescribe a medication to help ease your cat's anxiety. This medication is prescription, so we can not dispense it prior to meeting your cat. This means that if your cat is overly anxious at their visit, the first visit may be a "Fear Free consult" and we may dispense the medication and ask that you return another day after having given the medication to your cat. Thank you for taking the time to answer these questions. Our goal is to make you and your cat's visit as fear free as possible. We do often offer treats to your cat while here to help ease their stress. These are more often accepted when your cat is hungry. If you think about it, please withhold food for a few hours prior to the appointment to make sure your cat is good and hungry!EmailThis field is for validation purposes and should be left unchanged.