New Patient Registration

New Patient Registration

Welcome! Thank you for giving us the opportunity to care for your pet. To ensure the best care possible, please take a moment to fill out completely. We also ask that you fill out our Patient Pre-exam history form found on our website.
Registration
Please select one

New Client to the HospitalCurrent Client with New Pet
How did you hear about us?
Please let us know who referred you so we can thank them!
Owner's Name*

First NameLast Name
Co-Owner
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County*
County
Email*
example@example.com
Phone Number*

Area CodePhone Number
Phone Type
May we text this number?*

YesNo
Alt Phone Number

Area CodePhone Number
Alt Phone Type
May we text this number?

YesNo
We sometimes feature our SVH family on our facebook page! Please check yes if you consent to sharing your pet's picture, we will always respect your privacy.

Yes, it is ok to share photos of my petNo, my pet is camera shy!
Pet Health Information
Pet's Name*
Age or DOB*
Type of Animal

DogCatOther
Sex*
Has your pet been spayed/neutered?*

YesNoUnknown
Breed*
Color*
Previous Veterinary Hospital Name*
Previous Veterinary Hospital Phone Number

Area CodePhone Number
Any injury or illness in the past 30 days?*

YesNo
Please describe
Is your pet currently on any medications?*

YesNo
Please list below
Is your pet allergic to any drugs/medications/vaccines?*

YesNo
Please list below
Any food intolerance?

YesNo
Please list below
Authorization

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges in the care of the animal. I understand that these charges must be paid at the time of the release and that a deposit maybe required for surgical treatments.
Signature of Owner/Authorized Agent*
Method of payment*

CashCredit CardCare Credit
Should be Empty:

New Patient Registration

Registration

Pet Health Information

Authorization