Maywood New Client Registration Form

New Client Registration Form

Client Information
Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following:
Client Name *

First Name Last Name
Spouse's Name

First Name Last Name
Client Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Landline

Area Code Phone Number
Cellphone *

Area Code Phone Number
Email *
example@example.com
Do we have permission to use your pet's images on our practice's social media pages? *

Yes No
Payment Policy: I understand that The Maywood Veterinary Clinic does not accept payments on account. We require payment for services in full when services are rendered. In the case of non-payment, I realize that I am responsible for a collection agency fee of $16.00 and/or attorney fees necessary to collect the full amount due to The Maywood Veterinary Clinic. I further agree that in case of non-payment a finance charge of 1.5% per month (18% APR) will be charged. *

Yes No
Please sign your signature to acknowledge our Payment Policy: *

Clear
How did you become aware of our clinic?

Drove by Internet Personal recommendation
If a friend or family member recommended us to you, whom may we thank?

First Name Last Name

Please list the following information regarding your pet(s): *

PET # 1

PET # 2

PET # 3

NAME

BREED

DATE OF BIRTH (mm/dd/yyyy)

COLOR

SEX

SPAYED / NEUTERED?

Is your pet experiencing any of the following: *

Coughing / Sneezing / Nasal Discharge Vomiting / Diarrhea Lameness / Pain /Difficulty standing, playing, and or jumping Skin / Ear Irritation Lumps / Bumps Urine issues Appetite / Weight Changes Increased Thirst Behavioral Changes (Lethargy / Ataxia) Trauma / Body injury Other None - My Pet is Healthy
If answered yes to any of the above, please describe:
At Maywood Veterinary Clinic, we wanted to make it easier and more convenient for our clients to communicate with us. So we developed an App for our clients to use!

Now, clients can do things like request appointments, request refills on medications and products, request information updates, view pet reminders, upcoming appointments, recent prescriptions, etc. Clients can call us, get directions or email us with the push of a button from the App. You can also update how you'd like us to communicate with you by setting your preferences up (email, text, postcard).

Visit www.maywoodvet.com to download our App today!

Updates on COVID-19

Hospital Policies for All Appointments
If you or a member of your household have traveled within the last 14 days and/or are ill with COVID-19 or ANY OTHER illness, please have a friend/relative bring your pet in or wait to make your appointment for when your quarantine is over and/or you are feeling better. Please contact us to reschedule if need be. *

I understand the above statement
When interacting with staff employees it is required that you wear a mask properly covering your mouth and nose. We also request that you stay at a 6-foot distance when possible. *

I understand the above statement
Upon arriving to your appointment, please text 201-646-5001 to let us know that you are here. Please allow us up to five minutes to confirm that we have received your text message. This is our preferred method of check-in. Please only call if you do not have access to text as we are experiencing high call volume during this time. *

I understand the above statement
Following your pet's exam, we will e-mail you a secure link for payment. Once payment is received, the technician will escort your pet out to you. During this time, credit card payment is preferred. Please try to avoid cash or checks. *

I understand the above statement
Unless you have a true pet emergency, please refrain from engaging with the staff members you see assisting others in our parking lot. Please also do not honk your car horn to get the attention of our staff as this can be very scary for our patients. We understand that it is much easier to talk with a person to check in or ask for help, but these individuals are already helping others. Please text our office and someone will be with you as soon as possible. *

I understand the above statement
How do you wish to participate in your pet's exam? *

Virtually via Google Meet Curbside
*If you prefer Google Meet, please download the app prior to appointment. After the technician takes your pet inside, you will be invited via text message to join a virtual meeting of your pet's exam. Please join as soon as you receive the link as we cannot postpone beginning the exam due to our tight schedule.

*If you prefer curbside, you will receive a call from the doctor after your pet's exam has been completed.
Please list the cell phone number that we should call and/or text on the day of your visit: *

Area Code Phone Number
Please sign your signature to acknowledge our COVID-19 Policies: *

Clear
Should be Empty:

New Client Registration Form

Updates on COVID-19