Client Registration Form

CLIENT REGISTRATION FORM

Patterson Veterinary Hospital will NEVER share or sell your personal information.
Client's Name*

First NameLast Name
What is the best phone # to reach you?*
Area code and phone number
Is this a mobile phone number where you can receive text messages from us regarding appointments/patient care?*

YesNo
Alternate Phone Number (if any)*
Please provide an email where we can send invoices, vaccine reminders, exam reports and important messages. *
If you don't prefer NOT to be emailed, please write NO EMAIL
Your Mailing Address*

Home Address

CityState

Zip Code
Name of someone else you would like listed as a 2nd owner on the account (if any) and their phone number. This person will be authorized to bring your pet in and make decisions on medical care.
Name and Phone Number
How did you hear about us? (if one of our clients recommended you, please list their name so we can thank them.)*
Client's name, Facebook, Google, Instagram, Etc.
Pet's Name being seen at initial appointment*
What species is your pet?*

DogCatSmall MammalReptileBirdOther
What breed or mix of breeds is your pet? *
If you are unsure, your best guess is welcome!
What color is your pet?*
What is your pet's age and/or birthdate?*
How long ago did you acquire this pet?*
Gender*

Male/IntactMale/NeuteredFemale/IntactFemale/SpayedUnknown
Estimated weight?*

under 10lbs11-25 lbs25-50 lbs50-75lbs75-100 lbsOther
Where does your pet spend most of his/her time?*

Indoors ExclusivelyOnly goes outside to urinate/defecate.Spends time outside in contained area and/or with supervision.Exclusively outdoors.
How would you describe your pet's temperament?*
List any on-going medical issues your pet is being treated for. *
If none, wrote NONE
List any medication your pet receives including heartworm and flea/tick preventative.*
If none, write NONE
Name/location of your previous veterinary office where your pet has been treated. (If you do not have any information on previous history, write "unknown"*
Please indicate how we can obtain your pet's medical record PRIOR to the scheduled appointment.*

I authorize the veterinarian listed above to share my pet's record.I am attaching a photo or pdf file of my pet's records below.I am attaching vaccine records provided to me by a breeder or rescue organization.There are no known medical records for this pet.
If we are not calling your veterinarian, please attach a photo or pdf of your pet's vaccine record here.

Browse Files

Cancelof
I certify that I am:*

this pet's owner or legal guardian.an authorized caregiver by the pet's owner or legal guardian.
Do you give Patterson Veterinary Hospital permission to take you pets' photo for possible use on our website, Facebook or Instagram Page?*

Yes, you can share my pet's call name and photo.No, Only take a photo for identification purposes in my pet's confidential medical record.
All of the information that I provided is correct to the best of my knowledge*
Please type your name here
By signing at the bottom of this form, I indicate that I understand the following terms:
- I hereby authorize the veterinarian(s) of Patterson Veterinary Hospital to examine, prescribe for, and provide treatment for my pet(s).
- We accept major credit cards, cash, Carecredit/Scratchpay (checks accepted only from established clients)
- Full payment is due at the time services are rendered.
- We do not offer in-house financing or payment plans.
- I assume financial responsibility for all charges incurred in the care of my pet(s).
- I understand a deposit (or payment in full) may be required prior to treatment and/or hospitalization.
- All healthy animals admitted for services at Patterson Animal Hospital must be current on required vaccines.
- I agree to pay for required vaccinations if I can't provide proof/verification that they are up to date.
- A valid doctor/patient relationship (exam within one year) is required in order to approve and/or dispense prescription medication/food.
DISCLOSURE OF MEDICAL STAFFING HOURS: Patterson Veterinary Hospital has the following business hours:

Monday – Friday: 7:30am to 6:00pm, Closed on Saturdays, Sundays and most Holidays.

Patterson Veterinary Hospital has licensed medical staff during these times:

Monday – Friday: 8:30am to 6:00pm

There are no licensed medical staff members during the following times:

Monday through Thursday: 6:00pm until 8:30am the following morning,

Fridays: 6:00pm until Monday 8:30am. (Closed on Saturdays, Sundays)

Closed from the posted closing time on the eve of a holiday to 8:30am on the next business day.

*Non-licensed staff members are here at variable times during the weekend/holiday hours if there are pets to be cared for.*
Signature*

Clear
Signed On*

MonthDayYear
Should be Empty:

CLIENT REGISTRATION FORM

Patterson Veterinary Hospital will NEVER share or sell your personal information.