New Client Registration Form – Eastern PA Veterinary Medical Center

Client 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.

Owner's Name
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Preferred Phone Number for Contact*
Secondary Phone Number
Mobile Phone
Email*
Enter Email Confirm Email
Which Service will you be using?*
Estimated Time of Arrival*
: HH
MM
Reason for Visit*
Pet Information
Pet's Name*
Species*
or if other species
Breed (if known)
Color
Date of Birth or Age*
Special Identification (tattoo, microchip, etc.)
Sex
Date of last vaccines (if known)
Date Format: MM slash DD slash YYYY
Primary Veterinary Hospital Name:*
Primary Veterinarian Name:*
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
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
How Did You Hear About Us?
If other please specify:
Please choose the appropriate box for your pet:*
- CPR (Cardio Pulmonary Resuscitation) I understand that I am consenting to any and all efforts to be made on my pet's behalf, in the event my pet may require lifesaving intervention such as;cardio pulmonary resuscitation or any other medically necessary life saving treatments/ and or medications deemed necessary by a veterinarian to preserve life. I understand that I am responsible for all fees associated with CPR for my pet. CPR fee range $250 - $750.
- DNR - I am consenting to DNR. (Do Not Resuscitate) I do not want my pet to have any lifesaving intervention, in the event my pet may require but is not limited to; Cardio Pulmonary Resuscitation or any other medically necessary life saving treatments or medications, deemed necessary by a veterinarian in an attempt to preserve life. nd Choice
Consent*
Please Read and Sign – Must Be Signed For Hospital To Perform Any Services.
*The Emergency Exam Fee is $125.00*

The doctors and staff are authorized by me to perform diagnostic and therapeutic procedures dictated to be necessary for my pet’s well being. I understand preliminary medical plans will be discussed along with the attendant risks. It is also understood no guarantee will be made as to a result or a cure.

I UNDERSTAND PAYMENT IS DUE IN FULL AT TIME OF SERVICE, WE DO NOT DO ANY BILLING. (Pago al tiempo del servio). Estimates given for treatment may have a broad range to anticipate unforeseen events that can occur with an emergency case. I understand this is only an estimate and agree to be responsible for all charges incurred for treatment performed. A deposit will be taken upon admission to the hospital, the balance is due upon discharge. I certify that I am 18 years of age or older, I am the owner or agent of the owner of the above-described pet and have the authority to execute this agreement.
I agree to the privacy policy.
Please sign your name:*
First Last

Client Registration Form

Owner's Name

Pet Information