402-423-6939 staff@pahlincoln.com

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New Clients

Please complete this form with your basic information so that we may effectively and efficiently provide the service you deserve!

Name(Required)

First Last

Today's Date(Required)

MM slash DD slash YYYY

Address(Required)

Street Address Apartment Number City State ZIP Code

Primary Contact(Required)

First Last

Primary Contact Phone(Required)

Phone Type(Required)

Home

Cell

Primary Contact Email(Required)

Secondary Contact

First Last

Secondary Contact Phone

Phone Type

Home

Cell

Secondary Contact Email

Emergency Contact(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

Phone Type(Required)

Home

Cell

Authorized to treat pet?(Required)

Yes

No

How did you find out about our hospital? If you were referred by someone, who should we thank?(Required)

Pet's Name(Required)

Species(Required)

Dog

Cat

Breed(Required)

Color(Required)

Sex(Required)

Male

Neutered Male

Female

Spayed Female

Age(Required)

Date of birth (if known)

MM slash DD slash YYYY

Has your pet been to another vet before? If so, whom may we contact to obtain previous vet records?

Do you have another pet?(Required)

Yes

No

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2nd pet

Pet's Name(Required)

Species(Required)

Dog

Cat

Breed(Required)

Color(Required)

Sex(Required)

Male

Neutered Male

Female

Spayed Female

Age(Required)

Date of birth (if known)

MM slash DD slash YYYY

Has your pet been to another vet before? If so, whom may we contact to obtain previous vet records?

Hospital Policies:

Parkview Animal Hospital has established the following policies for the health and safety of your pets

A current Veterinarian-Client-Patient Relationship must be maintained in order to vaccinate or treat your pet, or to prescribe any medication.(Required)

I have read and understand

I understand in the event that my animal is in the care of Parkview Animal Hospital and requires treatment deemed necessary by the veterinarian, the Parkview staff will attempt to contact the owner or agent if time permits. Treatment will be done at the owner's expense.(Required)

I have read and understand

Canines

Unless deemed otherwise by the veterinarian due to sickness or injury, all dogs taken into the hospital areas are required to be vaccinated against: Rabies, Dist-Adeno2-Parvo, Leptospirosis, Bordetella(Required)

I have read and understand

Only vaccinations given by a licensed veterinarian, a USDA approved breeder, or a licensed pet store, and recorded on a legal medical record will be accepted as given.(Required)

I have read and understand

Felines

Unless deemed otherwise by the veterinarian due to sickness or injury, all cats taken into the hospital areas are required to be vaccinated against: Rabies and FVRCP(Required)

I have read and understand

Feline Leukemia vaccination is also recommended to any cat that goes outside, or is housed with other cats.(Required)

I have read and understand

A negative leukemia/FIV test is required prior to the first leukemia vaccination or prior to a leukemia booster if it is more than 12 months overdue.(Required)

I have read and understand

Administrative Policies:

Parkview Animal Hospital reserves the right to refuse service to anyone for any reason.(Required)

I have read and understand

Payment is due when services are rendered unless prior written authorization is given by an authorized member of the Parkview Staff. Acceptable forms of payment are: Cash, Check (with proper identification), Any credit card currently accepted at the time of service, Care Credit, and Scratchpay(Required)

I have read and understand

A service charge of 1.33%, as allowed by law, on the outstanding balance will be assessed for any bill not paid in full within 30 days of the last statement. The collection of delinquent accounts will be pursued by legal means. Rates may change at any time.(Required)

I have read and understand

Medical Information:

I hereby authorize Parkview Animal Hospital and its staff to obtain or release any current or past medical records to or from: Other veterinary medical persons or entities, Persons or entities responsible for payment of veterinary services provided, Any agent designated by the owner to assist them with their pets' care, Any entity necessary to collect a delinquent account, Any legal entity as required by law.(Required)

I have read and understand

Date(Required)

MM slash DD slash YYYY

Signature(Required)

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PAH

Your preferred Lincoln veterinary hospital.

Serving pets and their owners since 1983!
When you bring your pet to our veterinarian clinic in Lincoln, NE, you’re trusting their health and care to the very best the Lincoln area has to offer.

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Contact

P: 402-423-6939
E: staff@pahlincoln.com

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Hours

Mon – Fri: 7:30 a.m. – 6 p.m.
*Doctor available at 8am*
Sat: 8 a.m. – 12 p.m.
Sun: Closed
*Check-ins must arrive 30-min prior to closing*

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Location

1300 Infinity Ct,
Lincoln, NE, 68512

Have a question?

Get in touch! Complete the form below and a member of our team will be in touch with you shortly. If you’re in need of immediate assistance, please contact us at 402-423-6939 .

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