Owner's Name

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone*

Email*

Enter Email Confirm Email

Preferred Contact Method*

Call
Text
Email

Provide Preferred Contact Information

Co-owner's Name & Contact #

Name

First Last

Phone

How did you find out about our practice?

If Other, please specify:

If Personal 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

Are you or your spouse active duty or retired military?*

Yes
No

If yes please provide a military ID to staff

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 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

Would you like to add another pet?*

Yes
No

Second 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 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

Please list each Authorized (Family Members, Pet Sitters, Etc.) person(s) to make medical & financial decisions for your pets.

We can not provide services for your pet if the presenting party is not included on this form. Please include all spouses/significant others/emergency contacts and children over 18

Medical:*

Financial:*

PAYMENT POLICY: PLEASE READ AND SIGN

We will provide you with a written treatment plan. We require a deposit (half of the written treatment plan) for all hospitalized patients, surgeries and emergencies. For your convenience, as forms of payment, we accept Visa, MasterCard, Discover, American Express, Care Credit, Debit cards, personal checks, and cash. All payments are to be made as services are rendered. Accounts that are not paid in full are subject to a monthly interest rate of 1.8 %. Interest per year is not to exceed 21.6 %. Clients are responsible for all charges incurred and any collection fee necessary to collect on overdue accounts. A returned check fee of $25.00 will be charged for any returned checks.

Consent*

I agree to the payment policy above.

Client Signature*

New Client Registration Form