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
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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
Cancel
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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of
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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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