New Client Registration Owner's Name: Co-Owner Name: Address: City: Postal Code: Home Phone: Cell Phone: Co-owner phone Email: Previous Veterinary Hospital Do you have pet insurance? Yes No Insurance Company Policy/ Customer # #1 Pet's Name Species Cat Dog Other Breed Sex Female Male Color Are they Spayed or Neutered? Yes No Date Of Birth Are their vaccines up to date? Yes No Does your pet have any known health conditions or allergies? #2 Pet's Name Species Cat Dog Other Breed Sex Female Male Color Are they Spayed or Neutered? Yes No Date Of Birth Are their vaccines up to date? Yes No Does your pet have any known health conditions or allergies? #3 Pet's Name Species Cat Dog Other Breed Sex Female Male Color Are they Spayed or Neutered? Yes No Date Of Birth Are their vaccines up to date? Yes No Does your pet have any known health conditions or allergies? Date I hereby acknowledge and agree to the terms and conditions set forth. By signing below, I confirm my acceptance and understanding of these terms. Financial Agreement and Authorization of Treatment: I authorize the above-named pet(s) and agree, irrevocably, that in the consideration of the services to be rendered, I hereby obligate myself to pay the account in accordance with the regular rates and terms of the provider. As required by law, you are hereby notified that a negative credit report reflecting your credit may be submitted to a credit reporting agency if you fail to fulfill the terms of your credit obligations to our establishment. Should the account be referred to an attorney or collection agency for collection, the undersigned agrees to pay actual attorney's fees and collection expenses. A DEPOSIT MAY BE REQUIRED, AND FINAL BILLS ARE UPON RELEASE OF THE PATIENT. NO BILLING OR PAYMENT PLANS. Signature Of Owner Submit
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