If this is your first time visiting Smithfield Road Veterinary Hospital please complete our New Patient Form using anyone one of the methods below.

Option 1

Complete Online

You can fill out and submit our New Patient Form below, in advance online.

Option 2

Fill out Upon Arrival

If you rather, you can fill out the form when you arrive at our hospital.

New Patient Form

Owner Information

Owner First Name *

Owner Last Name *

Secondary Owner / Authorized Agent Name

Email *

Primary Phone *

Mobile Phone

Work Phone

Address *

City *

State *

Zip Code *

Employer *

Occupation *

Date of Birth *

How did you hear about us? *

Primary Care Veterinarian

Internet

Friend / Family

Community Event

Signage

Printed Publication

Radio

Other

Emergency Contact

Primary Emergency Contact Name *

Primary Emergency Contact Phone *

Secondary Emergency Contact Name

Secondary Emergency Contact Phone

Do you authorize your emergency contact(s) to make urgent treatment decisions if you are unreachable? *

Yes

Do you authorize your emergency contact(s) to receive patient information in addition to your primary care veterinarians? *

Yes

Patient Information

Pet Name *

Birth Date / Age *

Species *

Breed / Other Species *

Color

Vaccination Status *

Gender *

Spayed or Neutered? *

Presenting problem, special needs, concerns *

Primary Veterinarian Information

Please fill this section in if we are not your primary care veterinary hospital. By listing your primary care veterinarian, you are authorizing Smithfield Road Veterinary Hospital, PLLC to release patient information to the primary care hospital or veterinarian.

Primary Care Facility

Primary Care Veterinarian(s)

By submitting this form, I hereby authorize Smithfield Road Veterinary Hospital, PLLC to render medical care for my pet(s) as deemed necessary by the veterinarian. I understand that no guarantee can be given to the outcome of treatments and take it as my responsibility to comprehend any risks involved. I agree to pay for the cost of all services to which I consent to by written or verbal estimate. I understand that a deposit is required before diagnostics and treatments can be initiated and that payment in full is required prior to discharge of patient from Smithfield Road Veterinary Hospital, PLLC.

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Patients

Patients
New Patient Form
Pet Vet Tips
Financing Options

Emergencies Patient Account Login Log in to your pet's patient account to refill a prescription or access your pet's medical records.

Happy Tails from Clients

I've taken my pup Noodle to about 4 different vets for her chronic ear infections. The wonderful doctors at Smithfield have educated me on why her breed gets them, helped me find preventative care, and offered up a solution that no other vet had and it fixed her right up. It's way out of the way for me but with the prices as competitive as they are and the top-notch care, I won't be going anywhere else.
- Robyn F.

New Patient Form

Option 1

Complete Online

Option 2

Fill out Upon Arrival

New Patient Form

Owner Information

Emergency Contact

Patient Information

Primary Veterinarian Information

New Patients Are Welcome