Central Park Veterinary Clinic New Client Registration Form

Central Park Veterinary Clinic

New Client Registration Form

Thank you for choosing Central Park Veterinary Clinic for your pet's medical care. We are excited to meet you and your pet(s)!

Please complete the following form in order to create a New Client Account with us. We look forward to working with you, as a team, to provide the highest standard of veterinary care for your pet(s).

If you already have been to Central Park Veterinary Clinic in the past, you may already have an account. In this case, do not complete this form, but call us for the correct form for existing clients so that duplicate accounts are not created.

Click "NEXT" to get started!

New Client Policy: Unfortunately, we have a high rate of "no shows" for new client appointments. In order to best serve our clients and patients, we do require that this form be completed and submitted at least 48 hours prior to your scheduled appointment. We will also need to receive any prior medical history for your pet at least 48 hours prior to your appointment.
If we do not receive this information in time, we may have to reschedule or cancel your scheduled appointment.

If you have any trouble completing the form, please call to let us know at (603)742-1203.
Cancellation Policy: We require at least 48 hour notice to change or cancel an appointment. Clients who have a history of "no shows" or last minute cancellations may not be allowed to reschedule or may be charged a non-refundable deposit to schedule appointments. We appreciate your cooperation with this policy.
Please select an option below*

I understand the new client policy and cancellation policy

Client Information
Client Name (This is the primary owner of the pets listed with the account)*

First NameLast Name
Any person listed as a client or contact must be an adult, over the age of 18 and have permission to consent to treatment for the pet(s) on this account, as well as to receive communication about the pet(s).*

Yes. The client listed above is over the age of 18 and has authorization to consent to medical treatment and receive communications about any pet(s) listed on the account.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Client Contact Information
Home/Primary Phone Number*
Primary Phone is a*

Land lineMobile Phone
Mobile Phone Number (This number may be the same or different than that listed as the primary phone number above. Any text communications will be sent to this number if different than the main number.)
Work Phone Number (optional)
E-mail*
example@example.com
Information Privacy: Central Park Veterinary Clinic provides routine communication via email, as well as by text or phone. If you choose not to list an email address, or a cell phone number, you may miss out on some communications, including vaccine reminders, appointment reminders, test results, and other valuable communications. We may occasionally send out clinic information or newsletters, but not often. We will never sell or give away any client information, including email, without your permission.

Secondary Contact Person on the Account (optional)
Relationship to Primary Client:

SpouseSignificant OtherRelativeFriendOther
Any Client or Contact Person must be an adult, over the age of 18 and have permission to consent to treatment for the pet(s), as well as receive communication about the pet(s).

Yes. The secondary contact person listed above is over the age of 18 and has authorization to consent to medical treatment and receive communications about any pet(s) listed on the account.
Secondary Contact Person's Phone Number (optional)

Patient Medical History

It is vital that Central Park Veterinary Clinic receives copies of your pet's previous medical records at least 48 hours prior to the day of their first appointment.

It is your responsibility to have any and all previous records sent to CPVC. There are several options for sending medical records.

1. UPload the files using the "File Upload" button below.

2. Email- you, or your pet's previous veterinarian, can email records to Central Park Veterinary Clinic. Email Address: centralparkvet@comcast.net

3. Bring them in! You can drop off copies of medical records right at the clinic during our regular business hours. We are located at 252 Route 108, Somersworth, NH.

4. Send them by good, old-fashioned mail. If your appointment is more than one week away, there should be plenty of time to receive the records by "snail mail" at Central Park Veterinary Clinic, 252 Route 108, Somersworth, NH 03878. Then give us a call or send an email to let us know the records are on the way!

If we do not receive your pet's medical records prior to the day of their appointment, your appointment may need to be rescheduled for a later date. If you are having trouble getting copies of your pet's medical records, or if your pet has no known prior medical history, please call us at (603) 742-1203 or email at centralparkvet@comcast.net to let us know!
I will have my pet's medical records sent to Central Park Veterinary Clinic at least 48 hours (2 full business days) prior to my pet's first appointment. I understand that if this information is not received in time, I will be contacted to cancel or reschedule my appointment.*

I agree
File Upload- Upload your pet's prior medical records or any other documents you have for your pet(s) here and save the extra effort of sending them separately!

Cancelof
I have an appointment set up for my pet(s) on the following date (leave blank if no appointment is scheduled yet)

MonthDayYear
Date

Additional Comments or Notes
Is there any other information that you think we should know about you, your pets, additional pets you have, or any other comments? Please tell us! Examples: Fluffy is allergic to certain treats. Fluffy gets very nervous and might need a muzzle. I will need help transporting Fluffy into the building. Fluffy is great with people, but aggressive with other pets. Fluffy has had reactions to his vaccines in the past. Fluffy is very shy, please move slowly with him.
How did you hear about Central Park Veterinary Clinic?*
The staff and veterinarians at Central Park Veterinary Clinic welcome you to our CPVC family. Thank you so much for taking the time to fill out these forms. Getting this information ahead of time allows us to focus on you and your pet's care during your appointment. We are honored to be a part of your family's pet care team.

Please hit the "SUBMIT" button below to complete the form.
Should be Empty:

	Full Name	Phone Number	Relationship to Client
Alternate Contact #3 Information
Alternate Contact #4 Information