Online Registration

New Patient Information Form

Welcome to Haiku Veterinary Clinic, Your Other Family Doctor!

For immediate assistance, please call our office at (808) 235-6405.

Our goal is to provide you and your furry friend the best veterinary experience. When you arrive at our clinic, you will notice a more inviting, comfortable and calm environment. So you and your companion can spend some quality time together, we have provided this online form so we can gather some basic information before you arrive.

We strive to be environmentally conscious by reducing our use of paper products. All our medical records are maintained electronically.

Primary Guardian Information

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First Name:
Last Name:
Email Address:
Street Address:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Cell Phone:
Spouse Contact:
Spouse Phone:
How Did You Hear About Our Clinic?

If Referral, Who Should We Thank?
If an appointment is already scheduled, when?

Companion #1

Your Companion’s Name:
Is Your Companion a…
 Dog Cat
Breed?
Coloring?
Birth Date:
OR Pet’s Approximate Age:
Gender/Status:

Companion #2

(if applicable)

Your Companion’s Name:
Is Your Companion a…
 Dog Cat
Breed?
Coloring?
Birth Date:
OR Pet’s Approximate Age:
Gender/Status:

Companion #3

(if applicable)

Your Companion’s Name:
Is Your Companion a…
 Dog Cat
Breed?
Coloring?
Birth Date:
OR Pet’s Approximate Age:
Gender/Status:


Integrative Veterinary Medicine

At Haiku Veterinary Clinic, we offer Integrative Veterinary Medicine, which combines the best of traditional Western medicine with traditional Eastern medicine. These services include:

  • Acupuncture
  • Chinese herbal therapies
  • Cold laser therapy

Statement of Guardianship & Consent

I am the guardian and/or agent of the above patient and have the authorization to consent to treatment if and when it is needed.
Thank you for choosing Haiku Veterinary Clinic! For your convenience, we accept many forms of payment, including cash, all major credit cards, and personal checks.
At the conclusion of my visit with us, I will pay for all services rendered and products purchased.

I AGREE (confirm submission)

Please Fill Out The Form Below

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