New Client Form

Please complete the New Client Form below if this is your first time at District Eastern Market.

Client Information

First Name(Required)

Last Name(Required)

Preferred Names

Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Email(Required)

Phone Number(Required)

Is there anyone else you would like on your account?(Required)

Yes

Second Client Information

First Name(Required)

Last Name(Required)

Preferred Names

Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Email(Required)

Phone Number(Required)

Patient Information

Please tell us about your friend!

Name of Pet(Required)

Species(Required)

Dog

Cat

Please upload any pertinent or prior medical records below

Max. file size: 50 MB.

Breed (if known)

Color(Required)

Sex(Required)

Male

Female

Unknown

Is your pet spayed or neutered?(Required)

Yes

What is your pets date of birth?(Required)

Does your pet have any allergies to medications?(Required)

Yes

Please list all medications that the pet is currently taking, including dosage.

What is your pets favorite toy?

Tell us something interesting about your pet!

Do you have another pet you would like to register?(Required)

Yes

Second Patient Information

Please tell us about your friend!

2) Name(Required)

2) Species(Required)

Dog

Cat

2) Please upload any pertinent or prior medical records below

Max. file size: 50 MB.

2) Breed (if known)

2) Color(Required)

2) Sex(Required)

Male

Female

Unknown

2) Is your pet spayed or neutered?(Required)

Yes

2) What is your pets date of birth?(Required)

2) Does your second pet have any allergies to medications?(Required)

Yes

2) Please list all medications that the pet is currently taking, including dosage.

2) What is your pet's favorite toy?

2) Tell us something interesting about your pet!

If appropriate, please list your previous veterinarian / animal hospital

Is there anyone in your household allergic to peanut butter?(Required)

Yes

How did you become aware of our hospital? You may choose more than one option.(Required)

Drove / walked by

Website / social media

Google search

Rescue Group

Community Event

Previous client referral

Whom may we thank?

Reason for Appointment

Reason for Appointment?(Required)

Please list other reason for scheduling an appointment.

Policies and Procedures

We will gladly prepare a written estimate if you desire. Please ask one of the staff at your visit or in advance.

All major credit cards are accepted. We do not accept checks or Care Credit.

A credit card may be required to schedule an appointment. Clients who cancel an appointment with less than 24 hours notice or clients who fail to show for their appointment may have their card charged the prevailing examination fee. Surgical no-show clients may be charged $150.

Per District of Columbia regulations, the hospital must register all dispensed controlled medications. A request may be made to the PDMP to obtain information on all covered substances dispensed to a patient visiting our hospital.

Unless requested otherwise you give us permission to post tasteful pictured of your pet, identified by pet name only, on our social media and website.

Please note that unless stated in writing, we will release your pet’s medical history to necessary veterinary / specialty hospitals when requested.

I am responsible and agree to pay in full the total charges for services rendered at the time of discharge and any fees incurred for collection of said charges. I understand that the fees are based on treatment deemed necessary at the time of exam, treatment, or admission and that any estimate is subject to changed based upon services provided.

Signature(Required)

Today's Date(Required)

MM slash DD slash YYYY

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Comments

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Client Information

Second Client Information

Patient Information

Second Patient Information

Reason for Appointment

Policies and Procedures

What's Next

Call us or schedule an appointment online.

Meet with a doctor for an initial exam.

Put a plan together for your pet.

Where family pets find loving care