New Client Registration Form

File #:
Date:
Owner Name(s) *:
Address *:
City*:
State*:
Zip*:
Home Phone*:
Work Phone*:
Ext:
Cell Phone*:
E-mail Address*:
Driver's License#:
State
Expiration Date:
Patient #1 Name*:
Patient #2 Name:
Species:
Species:
Breed:
Breed:
Sex:
Sex:
Spayed?
Spayed?
Neutered?
Neutered?
Color:
Color:
Birthday:
Birthday:
Previous Veterinarian/Clinic:
Phone#:
How did you hear about us? If internet, please specify website*:
We accept these methods of payment:
Cash Debit MasterCard Visa American Express Discover Care Credit
We do not accept checks

We, our agents or assignees may call by telephone regarding your account. You agree that we, our agents or assignees may place such calls using an automatic dialing/announcing device. You agree that we, our agents or assignees, may make such calls to any telephone numbers you have provided including any mobile telephone or similar device. You agree that we, our agents or assignees may, for training purposes or to evaluate the quality of service, may listen to and record phone conversations you have with us and/or our agents or assignees.

I, the undersigned, understand and agree to the fact that it is the policy of this animal hospital to receive payment in full at the time services are rendered, and that a deposit may be required upon admission to the hospital for treatment. In the event that it becomes necessary to turn an account over for outside collection, I agree to pay all costs of collection to include a 20% collection charge on the total balance owed.

Signature*:

*By electronically signing this document, I acknowledge that I have read, understood, and accepted all of the information provided.

For the safety of all pets and people, please keep your pet restrained by leash or carrier at all times. Thank you!