New Client/Patient Registration Form

New Client/Patient Registration Form

Thank you for considering Bedford Veterinary Medical Center for your pet's needs. Please fill out our new client/patient registration form in entirety to ensure we can provide you and your pet with the best possible care.
Have you ever brought any pets to Bedford Veterinary Medical Center before? *

Yes No
Owner's Email *
example@example.com
Owner's Name *

First Name Last Name
Cell Phone Number *

Area Code Phone Number
Home Phone Number

Area Code Phone Number
Spouse/Partner

First Name Last Name
Spouse/Partner Phone Number

Area Code Phone Number
Owner's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Work Phone Number

Area Code Phone Number
Pet's name *
Upload a photo of your pet

Browse Files
Share your favorite photo! Cancel of
Species *

Dog Cat
Date of Birth/Age *
Breed & Color *
Sex *

Male Male Neutered Female Female Spayed
Primary Reason for Visit to Bedford Veterinary Medical Center *
Do you already have a scheduled appointmet? *

Yes No
Appointment Date & Time

Month Day Year
Date Hour Minutes AM/PM Option
Previous Veterinarian
Upload any previous medical records or history

Browse Files

Cancel of
Does your pet have Pet Insurance?
If yes, please list insurance company
How did you hear about us? *

Google/Online search Facebook Driving by Animal Shelter/Adoption Program
Please let us know if there is a current client we may thank for referring you to us.
Please list the names and types of other animals that you own
Do we have permission to use photos of your pet(s) on Facebook, Twitter, Instagram and our website? *

Yes No
AUTHORIZATION: I understand that I am responsible for services and for all charges incurred in the care of the my pet. I further understand that these charges will be paid at time of services and that a deposit may be required. *

First Name Last Name Date
Should be Empty: