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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.
If you or someone in your home is COVID-19 positive, you are required to have another person that does not live within the household bring the pet to our facility.
Owner's Name
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darrussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Preferred Phone Number for Contact
*
Secondary Phone Number
Mobile Phone
Email
*
Enter Email
Confirm Email
The person listed above is over the age of 18 years and is responsible for making both financial and medical decisions for the pet(s) listed below
*
If NO – please list the responsible party in the secondary contact below.
Yes
No
Secondary Contact Name
First
Last
Secondary Contact Phone
Which Service will you be using?
*
Emergency Service
Ophthalmology
Cardiology
Surgery
Estimated Time of Arrival
*
:
HH
MM
AM
PM
Reason for Visit
*
Pet Information
Pet's Name
*
Species
*
Dog
Cat
Rabbit
Ferret
Bird
Reptile
or if other species
Breed (if known)
*
Color
Date of Birth or Age
*
Special Identification (tattoo, microchip, etc.)
Sex
Neutered Male
Spayed Female
Male
Female
Unknown
Date of last rabies 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?
My Primary Veterinarian
Google
Family/Friend
Newspaper Ad
Facebook
Billboard
Other
If other please specify:
Please choose the appropriate box for your pet:
*
Please choose only one
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
Today's Date
*
MM
DD
YYYY
Time
*
:
HH
MM
AM
PM
Home
About Us
Who We Are
Team
Cardiology Staff
Emergency Staff
Ophthalmology Staff
Surgery Staff
Contact
Services
Cardiology Services
Emergency Services
Ophthalmology Services
Surgery Services
Pet Owners
What to Expect
Take A Tour
New Client Registration Form
Referring Veterinarians
Links