Primary Pet Owner Name *

First

Last

Contact Number *

Secondary Pet Owner Name

First

Last

Contact Number

Account Email Address *

Where all communications, reminders, medical records will be sent to

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact *

First

Last

Emergency Contact Number *

How did you hear about us? *

Due to the high demand for appointments and the increased frequency of missed or last-minute cancelations, we require a deposit for all New Clients when scheduling an exam. This deposit is applied to the account and then invoiced at the time of checkout. This deposit is non-refundable if the appointment is canceled/rescheduled less than 24 hours prior or the appointment is missed all together. *

I have read the above and understand

Pet's Name *

Species *

Breed

Color/Markings *

Sex *

Spayed/Neutered?* *

Pet's Date of Birth

How long have you had your pet? *

please choose days, weeks, months, or years below

Please specify the unit of time *

Previous Veterinarian *

Please list any known medical conditions: *

Please list any known allergies: *

Please list all current medications: *

Special/Prescription Diet

Kennel or Groomer

Is there any other important information you would like us to know about your pet?

Do you allow our hospital to use images of your pet on social media and our website? *

Yes
No

Instructions

We ask that services be paid at the time services are rendered. At this time, our hospital does not offer any payment plans or deferred billing. We routinely provide estimate for recommended treatment plans but please ask if costs are unclear. A deposit is required for any hospitalized patient. We accept the following forms of payment: cash, personal check, Care Credit and credit/debit including Visa, Mastercard, Discover, and American Express. All unpaid invoices will incur a processing charge of 1.5% after 30 days.

*Please note that when writing a personal check, a copy of a valid driver’s license will be needed for processing. There is a $35.00 fee for a returned check in addition to the fees that your bank may charge*

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

To help prevent the spread of infectious disease, we require that all hospitalized and surgical patients are current on the following vaccines. You must provide proof that your pet is currently up to date. Canine: Distemper/Parvo, Rabies, Bordetella Feline: Distemper, Rabies

Today's Date *

Signature *

Clear Signature

New Client/Patient Registration

New Client/Patient Registration Form

Location

Hours

Contact

For Emergencies Contact

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