New Customer Registration Form

New Client Registration

**Must be 18yrs of age or older and provide a Drivers License or State ID**
Primary Owner - (Must be at least 18 years of age) *

First NameLast Name
Preferred Pronouns:
Spouse / Partner/ Secondary Owner

First NameLast Name
Preferred Pronouns:
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
E-mail*
example@example.com
Secondary Email
example@example.com
How would you prefer to be contacted regarding your pet(s)?
In case of Emergency, please call First Name Last Name at Phone Number
How did you hear about us?*
If you were referred to us, who may we thank? First Name Last Name
Professional Fees are due at the time services are rendered.

Upon request, we will provide you with an estimate of fees for any hospital treatment, emergency care, surgery or hospitalization. A deposit prior to treatment will be required and will be determined based on the amount of the estimate.

To prevent the spread of infectious diseases and parasites, all in-patient and out-patient pets must be current on vaccinations and be free of parasites. Please note that patients being examined outside of a wellness exam will not receive vaccinations unless otherwise determined by the attending veterinarian.

I understand the above to be a strict policy of the clinic.

Owner's will be notified prior to the administration of any vaccinations.
We currently accept all major credit cards, cash and care credit. WE DO NOT ACCEPT CHECKS.

*Please note that all new clients will be required to leave a deposit in the amount of the current exam fee per pet being scheduled for the initial visit.
Yes, I have read and agree to the above
Yes, I consent to my pets photo being taken and posted on the internetNo, I do not wish to have my pets photo taken and used on the internet
Yes, I already have an appointment scheduled.No I have not scheduled yet.
New Patient Information
Pet Name*
Age/Date of Birth*
Species*
Breed*
Color*
Gender*
Is your pet Spayed or Neutered*
NoYesNo, But I would like more information about it.
Previous Veterinarian*
Previous Veterinarian's phone number
What brand of food does your pet eat (Please note wet or dry and amounts per day)*
Yesnonot sure
Second New Patient Information
Pet Name
Age/Date of Birth
Species
Breed
Color
Gender
Is your pet Spayed or Neutered
Previous Veterinarian
Previous Veterinarian's phone number
What brand of food does your pet eat (Please note wet or dry and amounts per day)
Previous Veterinarian's Phone Number
Previous Medical Records

Please upload previous medical records for your pet(s) at least 72 hours prior to your scheduled visit.
Previous Medical Records

Cancelof
Cancellation Policy

**Must be 18yrs of age or older **
At the Belvedere Veterinary Center, your scheduled appointment time is reserved just for you and your pet. We try not to overbook appointment times in order to provide excellent service and veterinary care. To this end we have allotted sufficient time to acquire an in-depth history, adequately examine your pet and discuss treatment options with you in detail. In return, we ask that you help us by keeping your scheduled appointments, arriving 5 minutes early to complete registration documentation and by notifying us a minimum of twenty-four (24) hours in advance if you are unable to do so. When we receive advanced notice of cancellation, it allows us to accommodate other patient's medical needs.

Missing two appointments with less than 24 hours notice: All future appointments must be prepaid in advance. This deposit is non-refundable.

By completing this form, you acknowlege and accept the terms of the Belvedere Veterinary Center cancellation policy.

Thank you for your understanding and cooperation.
Yes, I have read and agree to the above. My signature is below.
Signature*

Clear
Should be Empty:

New Client Registration

New Patient Information

Second New Patient Information

Previous Medical Records

Cancellation Policy