New Client Registration

Owner Information

Owner #1

First Name: *

Last Name: *

Date: *

Address:

Apartment, suite, etc:

City:

State/Province:

ZIP / Postal Code:

Phone Number: *

Occupation:

Employer:

May we call you at work if necessary? *YesNo

Email Address: *

Owner #2

First Name: *

Last Name: *

Date: *

Address:

Apartment, suite, etc:

City:

State/Province:

ZIP / Postal Code:

Phone Number: *

Occupation:

Employer:

May we call you at work if necessary? *YesNo

Email Address: *

How did you find our hospital? *Hospital SignInternetIndividual

Who may we thank for referring you?

Pet Information

Pet's Name: *

Breed:

Color:

DOB: *

Sex: *

Spayed/Neutered:

Indoor/Outdoor:

Pet obtained from (breeder, shelter, etc.):

Allergies?

Food (brand & dry or canned):

Previous illness or surgery:

Medical History/Vaccinations

Please have available a copy of your pet’s records or

Previous Veterinarian (for records):

Phone:

PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE RENDERED.

For your convenience, we accept cash, Visa, MasterCard, Discover, CareCredit and Debit cards.

We will gladly prepare a written estimate if you desire; please ask the veterinary technician or the doctor.

I understand that by signing this document I authorize medical treatment for my pet(s) and intend to pay for services on the date(s) performed. I assume financial responsibility for all charges incurred for services rendered to the patient(s), including any legal, collection, billing and/or interest fees (currently 1.5% monthly – APR 18%) incurred as a result of my failure to meet this responsibility. For accounts sent to a third party for collection, a fee of up to 35% of the unpaid balance may be added to your account. I also consent to the release of medical information.

I acknowledge and agree to comply with the following cancellation policy: If I do not show up for my pet’s scheduled appointment and I have not notified your office at least 24 hours in advance, I will be required to pay a missed appointment fee of $50.00. The missed appointment fee for any surgical or dental procedure is $125.00 I also consent to the release of my pet’s medical information.

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Owner Information

Pet Information

Medical History/Vaccinations

Please have available a copy of your pet’s records or