New Client Registration Form

Owners Name:*

First NameLast Name

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email:*

example@example.com

Phone Number:*

Area CodePhone Number

Alternative Phone Number:

Area CodePhone Number

Dogs Name:*

Breed/Type:*

Dog's Age:*

Gender:*

MaleFemale

Spayed/Neutered:*

YesNo

Veterinarian Name /Clinic Name: *

Vet or self referred ? *

Main problem / Vet's Diagnosis:*

Please briefly describe the problem for which your dog is being seen.*

When did the problem begin? *

Describe how it happened, if known.

Medical History

Please list any medications or supplements your dog is currently taking. *

Please list any other surgeries, illnesses or medical problems (include dates if known). *

Are your dogs immunizations /vaccines current?

YesNo

If using titers are these current?

YesNo

Polices and Agreements

Thank you for for choosing Well Paws K9 Rehab as the rehabilitation provider for your pet. Please read the following policies:

1. The client accepts full responsibility and agrees to pay all charges, in full, at the time of service. The client understands that Well Paws K9 Rehab, LLC does not offer payment plans. If the client uses pet insurance, an invoice can be provided for seeking reinbursement. Preapproval is the client's responsibility. There are NO refunds in the event of denied claims.

2. Well Paws K9 Rehab LLC, accepts the following forms of payment: Cash, check, credit/debit cards.

3. The client understands that all returned checks will be charged a $25.00 handling fee. The full amount of any outstanding balance will be due within 15 days from the written notice to prevent a civil action for three times the face amount of the check, but not less than $100.00 and that,in such civil action, the court may award court costs and reasonable attorney's fees.

4. Well Paws K9 Rehab, LLC offers packages of treatment sessions to facilitate the rehabilitation of your pet. Purchased package sessions must be used within 6 months of their purchase date, otherwise Well Paws K9 Rehab reserves the right to terminate the package, and any unused sessions will not be refunded .

5. Well Paws K9 Rehab, LLC will make every attempt to schedule follow-up visits at the time of service. In the event this doesn't happen, it is ultimately the client's responsibility to contact us to schedule the next appointment.

I have read and understood the above policies and procedures:*

YesNo

Please verify that you are human*