New Client/Patient Registration

Online Registration Form NEW CLIENT
Owner Information
Full Name*

First NameLast Name
Cell Phone Number*

Area CodePhone Number
Is it ok to communicate with you via SMS messaging (text)?*
Optional Additional Phone Number

Area CodePhone Number
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please take photo of the front your driver's license *this is secure and HIPPA compliant**
If you are not comfortable submitting the DL picture now, we will need to see it in person at the beginning of your appointment.
Birth date*

MonthDayYear
Date
Driver's License Number*
Driver's License Number*
Employer*
Pet Information
Pet name*
Breed*
Pet Gender*
Color*
Birthday*

MonthDayYear
Previous Veterinary Care Provided By:*
clinic or doctor name, if known - or none/NA
Vet Records

Browse Files
Please attach any records you have about previous veterinary care Cancelof
Please upload a picture of your pet for your file

Browse Files

Cancelof
Or take a photo of your pet now
General
How did you hear about Log Cabin?*
If you were referred by someone, who?*
May we use pictures of your pet for informational posts on social media? (No personal information will be posted)*

Yes to Social MediaNo to Social Media
Payment is due at the time services are rendered. For your convenience, we accept all of the following: Visa, Mastercard, Discover, Personal Check, Cash, and Care Credit.

I assume responsibility for all charges incurred in the care of any animal on this account. I also understand that these charges will be paid at the time of release and that a deposit may be required for treatment.
Signature of Owner or Responsible Party

Clear
Should be Empty:

Online Registration Form NEW CLIENT

Owner Information

Pet Information

General