New Customer Registration Form

Client Information Sheet (updated)
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Alternate Phone Number *

Area Code Phone Number
E-mail *
example@example.com
Clients Date of Birth *

Month Day Year
CALIFORNIA STATE LAW REQUIRES US TO GET OUR CLIENTS DATE OF BIRTH TO DISPENSE CERTAIN TYPES OF MEDICATIONS SUCH AS PAIN RELIEVERS, SEDATIVES, AND OTHER CONTROLLED MEDICATIONS.
Clients Drivers Licence *
Place of Employment
Work Phone Number
Spouse/Relative/Significant Other Name

Area Code Phone Number
How did you hear about us? *
(Facebook, Google, Yelp, ect.)
Other *
Overnight Staff:

ABC Veterinary Hospital is not a 24-hour hospital facility. An overnight technician is called in for all critical care patients that stay overnight.
Note:

I assume responsibility for all the charges incurred in the case of this/ these animal(s). I also understand that these charges will be paid at time of service. Should my account become delinquent, I assume responsibility for all collection fees in addition to the amount of my bill. The forms of payment accepted are Visa, MasterCard, American Express, Cash, and Care Credit. WE DO NOT ACCEPT CHECKS.
Signature

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Client Information Sheet (updated)