Download New Client Registration Form

WELCOME TO PET HOSPITAL CLIENT REGISTRATION
HOW DID YOU HEAR ABOUT PET HOSPITAL? (Please check)
Advertising: Local Flavor AD_____ Hometown OC Magazine AD _____ Money Mailer AD_____ Other_________
What in the AD helped you decide to come to this hospital?___________________________________________
Online: Google_____ Our Website______ Facebook______ Twitter_______ Instagram________ Other__________
Personal Referral ______: Who may we thank? Name First/Last___________________________________________
Other Referral Sources: Petsmart___ City___________ Petco____ City____________ Wagon Train____ Petopia____
Farmer's Market____ Pet Event____________________ Other______________
Pet Rescue_________________ Pet Sitter____________________ Other Vet__________________
Referred by Location ______: Specifically: Drove by ( )
Near home ( ) Stater Bros ( )
Saw Banner ( ) Other ( )
Today's Date
Owner’s Name _________________________________ Spouse’s Name ________________________________
Your Employer _________________________________Work Phone ____________________________________
Spouse’s Employer ______________________________ Work Phone _________________________________
Home Address ____________________________________________________________________________________
City
State
Home Phone_____________________________________
Zip
Cell Phone _________________________________
Drivers License#_________________________ (For your protection we ask that we have record of your license)
Your D.O.B.
(We will need this on file for dispensing any controlled drugs)
E-mail _______________________________ @ ________________________________
(Our preferred method for confirming upcoming appointments is via email or text. You will also be able to access your pets personal health portal
through our website. Your email will be used as your login. You can also create your personal preference to opt in or out of hospital specials, vaccine
and service reminders, and newsletters.)
*Any pet not picked up within the time required by California Civil Code shall be determined abandoned by owner and
will be handled according to California Civil Code. I understand this action will not, however, relieve me from paying all
charges for services rendered and all legal and/or court costs incurred in connection with collection and said fees.
* Photo Release: I grant Pet Hospital and its representatives and employees the right to take photographs of me and/or my
pet and to copyright, use and publish the same in print and/or electronically. I agree that Pet Hospital may use such
photographs of me and or my pet with or without my name and for any lawful purpose, including for example, such
purposes as publicity, illustration, advertising, and web content. Please check one below.
( ) The above may take photos of me and/or my pet.
( ) The above may NOT take photos of me and/or my pet.
Payment in full is required at the time services are rendered. We are unable to extend credit. A deposit may
be required upon admission of patient in to Pet Hospital. For any outstanding balances there are monthly $2.00
billing and 1.5% interest fees.
We accept Cash, Check, Visa, Mastercard, Discover, TAC, and Care Credit. There is a $200.00 minimum for
Care Credit transactions.
I, the undersigned, assume financial responsibility for all charges incurred to patient at Pet Hospital and agree to
pay all such charges at the time of release of such patient.
___________________________________________________________
Signature of Owner or Authorized Agent 18 years or older
____________
Receptionist
TELL US ABOUT YOUR PET: NAME ___________
D.O.B._______________
Circle Sex: Male / Neuter OR Female / Spay Circle Species: Canine Feline Bird Reptile Rodent Other
Breed______________________________ Color: __________________ Markings___________________
Pet’s Diet:
Dry ( ) Can ( ) Treats:______________________
Is your pet on any medications? If so, which: _____________________________________________________
Allergies?: _________________________________ Behavioral problems?:_____________________________
Chronic medical conditions?: _________________________________________________________________
Pet Microchipped: Y / N #:_____________________________ AKC Registered: Y/N #:__________________
Pet Health Insurance: Y/N Company:
VACCINES ARE REQUIRED FOR ALL PETS BEING ADMITTED FOR BOARDING, GROOMING OR TREATMENT.
PLEASE ATTACH YOUR PET'S VACCINE RECORDS OR NOTE WHERE THEY WERE DONE ALONG WITH PHONE
NUMBER OF CLINIC AND WE WILL CONTACT THEM. ANY PET PAST DUE OR WITH NO HISTORY MUST BE
VACCINATED IN ORDER TO BE ADMITTED.
Name of Facility _______________________________________________ Phone_______________________
REQUIRED VACCINES DOGS: DAPP, RABIES, BORDETELLA 6 MO
CAT: FVRCP, RABIES, FELV (if under 3yrs old)
__________________________________________________________________________________________
For Office Use Only :
Verified vaccines: DAPP Date done__________ Rabies Date done__________ Bordetella Date done________
FVRCP Date done _________ Rabies Date done_________ FELV Date Done_________
Verified by ________________
TELL US ABOUT YOUR PET: NAME ___________
D.O.B._______________
Circle Sex: Male / Neuter OR Female / Spay Circle Species: Canine Feline Bird Reptile Rodent Other
Breed______________________________ Color: __________________ Markings___________________
Pet’s Diet:
Dry ( ) Can ( ) Treats:______________________
Is your pet on any medications? If so, which: _____________________________________________________
Allergies?: _________________________________ Behavioral problems?:_____________________________
Chronic medical conditions?: _________________________________________________________________
Pet Microchipped: Y / N #:_____________________________ AKC Registered: Y/N #:__________________
Pet Health Insurance: Y/N Company:
VACCINES ARE REQUIRED FOR ALL PETS BEING ADMITTED FOR BOARDING, GROOMING OR TREATMENT.
PLEASE ATTACH YOUR PET'S VACCINE RECORDS OR NOTE WHERE THEY WERE DONE ALONG WITH PHONE
NUMBER OF CLINIC AND WE WILL CONTACT THEM. ANY PET PAST DUE OR WITH NO HISTORY MUST BE
VACCINATED IN ORDER TO BE ADMITTED.
Name of Facility _______________________________________________ Phone_______________________
REQUIRED VACCINES
DOGS: DAPP, RABIES, BORDETELLA 6 MO
CAT: FVRCP, RABIES, FELV (if under 3yrs old)
__________________________________________________________________________________________
For Office Use Only :
Verified vaccines: DAPP Date done__________ Rabies Date done__________ Bordetella Date done________
FVRCP Date done _________ Rabies Date done_________ FELV Date Done_________
Verified by ________________