Patient Registration Form

Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.

Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.

Before completing this form, please review our Client Rights and Responsibilities

Patient's Name *

Client / Owner Information

Your Name *

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Cell Phone

Home Phone

Work Phone

Your Email *

Confirm email *

Can you receive text messages? *

Yes

Spouse / Co-Owner Information

Your Name

Your Email

Confirm email

Cell Phone

Work Phone

Can they receive text messages?

Yes

If Client Referral, is there someone we can thank for this referral?

Please use this area to give us any other relevant information about yourself or your family

Marketing

Do you authorize permission to use any photos taken of your pet on our social media? *

Yes

Doctor Referral

Doctor's Name

Hospital

City/Town

State/Province

Doctor Phone

We offer care plans to help keep your new pet their healthiest. Care plans outline the vet-recommended preventive care your new pet needs while allowing you to pay for a year’s worth of care with manageable monthly payments. That way, you start your new pet on the best path toward a happy and healthy life. Would you like to hear more?

For additional information about our plans CLICK HERE

Terms of Service *

I agree to the consent policy.

I hereby authorize the veterinarian to examine, prescribe for, and/or treat the above described pet(s). As the owner or acting on behalf of the owner, I assume responsibility for all the charges incurred in the care of this animal. I understand that payment is due at the time of service and cash or checks are not accepted. I am over the age of 18.

I hereby authorize the veterinarian to examine, prescribe for or treat the above-described pet(s). I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges must be paid in full, at the time of release of the pet.

Signature *

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Patient Registration Form

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