New Client RegistrationWelcome! Use the form below to register your pet with our hospital. If you prefer a paper copy, you can click this link to download. Client Information Full Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Primary Phone * (###) ### #### Secondary Phone (###) ### #### Email * I do not wish to receive email reminders for vaccines. Significant Other (S.O.) S.O. Phone Number (###) ### #### Emergency Contact Emergency Contact Phone Number (###) ### #### Additional Contact Additional Contact Phone Number (###) ### #### Employer Employer Phone Number (###) ### #### How did you learn about us? * Community Event Facebook Flyer/Coupon Internet Search Road Sign Website Referred by If referred, by whom? Number of household pets * Number of Cats Number of Dogs If other, please specify: Pet Information Pet Name * Pet Type * Cat Dog Other (specify below) If other, please specify: Breed Age (D.o.B. if known) Sex * Male Neutered Female Spayed Undetermined Where did you get your pet? * Breeder Family/Friend Pet Store Rescue/Shelter Stray Other If other, please specify: Has your pet received any medical treatment prior to today? * Yes; copy of history provided Yes; no copy of history provided No Unknown history Are there any health or temperament concerns of which we should be aware? * Allergies Behavioral Cage/Room Aggression Chewer/Shredder Dental Diabetic Dog Aggression Ear(s) Eye(s) Fatigue Food Aggression Gagging Item Possessive Mobility Difficulties Neurologic Orthopedic Seizures Separation Anxiety Skin Other (specify) If other, please specify: Pictures/Video: Pets and Vets as Partners would like to use, reproduce, and/or publish photographs and/or video that may pertain to your pet including their image, likeness and/or voice without compensation. This material may be used in various broadcasted public service advertisements (PSA’s), publications, public affairs, recruitment materials, and/or for other related endeavors. This material may also appear on the Pets and Vets as Partners website and/or Facebook page. * Yes, I give authorization to Pets and Vets No, I do not authorize Pets and Vets Finances: By checking the box below, I hereby authorize the veterinarian to examine, prescribe for, and/or treat the above described pet. I agree to pay the rate for pet care provided put into effect on the date my pet is checked in to Pets and Vets as Partners. I further agree that in the event the charges are not paid when due that I must remit full payment in a timely fashion. If full payment is not made within a timely manner then the account will receive a finance charge for every 30 days past its delinquency. Further delinquency, typically exceeding 90 days, will merit my account being turned over to collections if I am unable to be contacted to have arrangements made. Should the services of an outside agency be required for collection of the account, I agree to pay costs of collections including but not limited to collection agency fees, attorney's fees, interest, and court costs. By clicking this box and electronically signing below, I agree to the terms and conditions listed above. Name First Name Last Name Thank you!
