Aston New Client & Patient Registration Form

New Client Registration Form:
Client Name:*

First NameLast Name
Date of Birth*
mm-dd-yyyy
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:*

Area CodePhone Number
Cell Phone:

Area CodePhone Number
Work Phone:

Area CodePhone Number
E-Mail Address:*
example@example.com
If you would like to receive reminders by E-Mail please provide your address.
Person to contact in case of emergency (third party):
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:

Area CodePhone Number
Work Phone:

Area CodePhone Number
Cell Phone:

Area CodePhone Number
How did you find us?*

Referred by friendOther VetRescue GroupWebsiteSign/Drive-bySocial MediaFacebookTwitter
Your Friend's Name:
If you were referred by a friend, please give us their name so we may thank them!
New Patient Registration Form:
Pet's Name:*
Breed:*
Date of Birth:*
mm-dd-yyyy
Microchip or Tattoo Number:
Color:*
Sex:*
History of any previous surgery, treatments, or medications:
Name of Previous Veterinarian:
Address or Phone Number with Area Code, if possible
Dates of Last Vaccinations - Canine:
Dates of Last Vaccinations - Feline:
If your pet is hospitalized, we will make attempts to reach you at the phone numbers you provide on treatment day. If we are unable to make contact with you, do you authorize any necessary treatments?

YesNo
PAYMENT POLICY FOR SERVICES RENDERED

For your convenience, we accept cash, checks, Visa, Master Card, Discover, American Express and debit cards. We will be happy to discuss any fees with you before your appointment or give you an estimate at any time for services. It is our policy to charge $25.00 for any returned checks. There will be a finance charge applied to all accounts unpaid after 30 days. Finance charge is computed by a periodic rate of 1.50% per month, which is the annual percentage rate of 18.00%. There is a minimum finance charge of $9.00 per month.
FINANCIAL RESPONSIBILITY AGREEMENT

I, the undersigned, understand and acknowledge that if an account balance is not paid in a timely fashion, I will be responsible not only for the balance due but any collection, reasonable attorney fees, and /or court costs that are incurred in the collection process. I understand that Aston Veterinary Hospital reserves the right to add an additional twenty-five to fifty percent fee if my account is sent to outside credit collections and that the Aston Veterinary Hospital will report delinquent accounts to all credit reporting agencies.
I have read the Payment Policy and the Financial Responsibility Agreement and understand its contents.
Print Name:*

First NameLast Name
Date:*

MonthDayYear
Please enter today's date
Signature:*
Should be Empty:

New Client Registration Form:

New Patient Registration Form: