New Client Registration Form

Owner's Name

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Day-Time Phone*

Mobile Phone*

Email*

Enter Email Confirm Email

Preferred Method of Contact*

Phone
Text
Email

How did you select our hospital?*

Drive-By
Animal Control
Humane Society
Dex Yellow Pages
DexKnows Online
Google
Yahoo
Yelp
Other...

If Other, please specify:

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

Co-owner's Name & Contact #

Name

First Last

Phone

Pet Information

Pet's Name*

Species*

or if other species

Breed (if known)

Color

Date of Birth or Age (if known)*

Special Identification (tattoo, microchip, etc.)

Sex*

Previous Veterinary Practice (if any)

Previous Veterinarian (if any)

Date of last vaccines (if known)

What vaccines were given at this time

Is your pet on any medication or supplement?*

Yes
No

If Yes, please list the medication or supplement

What Brand of food does your pet eat?*

Does your pet have allergies or drug reactions?*

Yes
No

If Yes, please list the allergies and reactions

Are there any current or past medical conditions of which we should be aware?*

Yes
No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Please use the following box to give us any other relevant information about your pet

Appointment*

Would you like us to contact you to schedule an appointment?

Yes
No
An Appointment Has Already Been Scheduled

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Payment IN FULL for ALL services is due at the time of service. We do NOT routinely bill clients for services rendered. An "Ill-Pet" Examination or "Well Pet" office call (vaccines etc.) for dogs or cats during normal business hours is $50 currently; ANY additional tests, treatments, or medications are additional costs. Prescriptions are non-refundable by law. We accept Cash, Personal Checks with identification, VISA, Master Charge, American Express, Discover Card, and CareCredit.Deposits are required before hospitalizing any ill patient; the balance for all fees is then due when the services are completed. Unpaid accounts are assessed a 1.5% finance charge per month ($2 minimum fee). Returned checks are assessed a $20 fee (or the maximum allowed by law). As our client, you agree to pay for any collection or legal costs incurred in the collection of any debt (up to 33.33% of the total fees). Any debt upon being 10 days overdue may be turned over to a collection agency. You also give us permission to release records to other veterinary hospitals, boarding or grooming facilities or other animal care facilities when requested by you (or any agent of yours) [whether by phone, FAX, email, or in writing] in the future. You also give us permission to use images or video of your pet for online sites such as our business web site, web search engines, and social media such as Facebook. No personally identifiable information shall be released in such a use.

Client Signature*

Owner's Name

Co-owner's Name & Contact #

Pet Information

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Contact Us

Hours of Operation

Emergencies