Site Accessibility Features: Skip to page menus

Reset Website Accessibility

 Site Menus Section  Skip to page content 
    


 Home
 About Us  Our Mission
 Our Story
 Our Doctor Team
 Our Leadership Team
 Tour The Hospital
 Our Location
 Careers
 Forms  Client Authorization Form
 Hospital Authorization Form
 Medical History Upload Form
 Boarding Express Check-in Form
 Prescription Refill and Food Order Request Form
 Breeding Questionnaire Male
 Breeding Questionnaire Female
 Resources  Emergency
 Online Pharmacy
 Hospital Policies
 Angel Fund
 ePet Health
 Pet Food Recalls
 Pet Insurance
 Pet Health  Pet Health Checker
 Pet Health Library
 How-To Videos
 Our Blog
 Pet Health News
 Services  Wellness  Feline Wellness
 Canine Wellness
 Surgery
 Internal Medicine  Ultrasound & Echocardiogram
 Radiology & Endoscopy
 In-house Laboratory
 Dental Care
 Reproduction & Breeding
 Boarding
 Grooming
 End of Life Care
 Additional Services  Laser Therapy
 Microchipping
 Health Certificates & International Travel
 Contact Us
 Make Appointment

Client Authorization Form

Please fill out this form prior to your first scheduled visit to our practice.

Name*
First Name Last Name
Phone*
Email*
Secondary Name
Please enter if you have anyone else in your household who is an owner of your pets/authorized (spouse, significant other, family member)
First Name Last Name
Phone
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
I declare that I am/we are 18 years of age or older and am/are the legal owners(s) of the patients listed in my file and have sole authorization to make decisions regarding my pet(s):*
- Yes
- No
We, North Penn Animal Hospital, use our social media pages (i.e.: Facebook, Instagram and YouTube), website and TV slideshow to share pet photos, videos and interesting stories. However, we cannot do it alone! Will you help us by granting permission to use photos/videos of your pet(s), their story and details of his or her medical history to help educate other clients? We will never share your name or your pet’s last name. If at any time you wish to have your pet’s photos, videos or stories removed, please alert our staff*
- Yes
- No
I authorize the release of my pet's medical and vaccine records to grooming, boarding, rescue adoption and veterinary facilities without signed release.*
- Yes
- No
I hereby authorize the veterinarian to examine, prescribe for, treat, or perform surgery or emergency care on my pet(s). I assume responsibility for all charges incurred in the care for this animal. I also understand that these charges will be paid in advance or at time of release.*
- Yes
- No
In order to keep costs down, we are unable to bill or carry accounts. Payment for all services and products must be paid in full at time of visit or discharge. If for any reason your pet is admitted into the hospital, we will require a deposit, which equals 1/2 of your pet’s estimate costs for his/her hospitalization. For your convenience we accept Cash, Check, Visa, MasterCard, Discover, American Express and offer CareCredit to qualifying clients.*
- I agree
- I disagree
Authorization*
Please enter your name and date to authorize.
Client Signature Date
File
Prior to your visit, please upload your pet(s) records below or email to clientcare@npah.com
Drop files here or

Make An Appointment Today

Ready To Join Our Pet Family?

Make An Appointment

Contact

Hospital: 215-855-5853 Boarding: 215-855-3739 Fax: 215-855-9337

1200 Welsh Road Lansdale, Pennsylvania, 19446

Hospital

Monday-Friday: 8 am–8 pm Saturday: 9 am – 2 pm Sunday: Closed

We are closed on the 1st and 3rd Wednesday of the month from 2-3:30 pm for our staff meeting.

Boarding

Monday – Friday: 9 am-12 pm and 4 pm-6 pm Saturday & Sunday: 9 am -12 pm

Please note: The boarding office is closed on holidays for drop-off and pickup.

Client Signature	Date