New Client/Patient registration form
Thank you for considering Papillion Animal Hospital for your pet's needs. Please fill out our new client/patient registration form in entirety to ensure we can provide you and your pet with the best possible care.
Have you been to our Hospital before?
*
Yes
No
Will this be the first visit to Papillion Animal Hosptial for this specific pet?
*
Yes
No
Do you have a scheduled appointment?
*
Yes
No
I submitted an online appointment request
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Primary Phone Number
*
-
Area Code
Phone Number
Secondary Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Spouse/Partner Name
First Name
Last Name
Spouse/Partner Phone Number
-
Area Code
Phone Number
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Pet's Name
*
Upload a photo of your pet
Browse Files
optional
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of
Species
*
Dog
Cat
Other
Date of Birth/Age
*
Breed and Color
*
Sex
*
Male
Female
Male, Neutered
Female, Spayed
Are you fostering the pet for a Rescue organization?
*
Yes
No
Will you or the Rescue organization be responsible for payment to PAH?
*
I will be responsible for payment
The Rescue will be responsible for payment
Name and contact information for Rescue organization?
*
Primary reason for visit to PAH?
*
Previous Veterinarian
Upload previous veterinary records
Browse Files
Please upload if available
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How did you hear about us?
*
Referral
Google/Internet Search
Nextdoor
Papillion Days
Rescue/NHS
Facebook/Instagram
Print Ad
Sign/Walk In
Another Animal Hospital
Please let us know who we may thank for referring you to PAH.
Do we have permission to use photos of your pets(s) on our social media platforms?
*
Yes
No
PAH uses Vet2Pet and Vetsource to email reminders about upcoming appointments and services that are do. Do we have permission to email these reminders to you?
*
Yes
No
I understand that I am responsible for services and for all charges incurred in the care of my pet. I further understand that these charges will be paid at time of service.
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