New Patient Registration Form

New Patient Registration

Please complete this form if you are an existing BVC client with a new pet
Primary Owner*

First NameLast Name
Primary Phone Number*
E-mail*
example@example.com
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)*
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)
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, out-patient and grooming pets must be current on vaccinations and be free of parasites.

I understand the above to be strict policy of the clinic and authorize the doctors to provide my pet(s) with vaccinations and parasite control as needed.

Please note that two missed or cancelled appointments with less than 24 hours notice will result in the need to leave a deposit for all future appointments. The amount of the deposit will be the current exam fee per pet being scheduled.

We currently accept all major credit cards, cash and care credit. WE DO NOT ACCEPT CHECKS.
I have read and agree to the above*

Yes, I have read and agree to the above
Here at BVC, we LOVE to take photos of our amazing patients. We may even use your pet on our social media pages! If you are PAWsitively as excited as we are please check YES!*

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
Have you already contacted Belvedere Veterinary Center to make an appointment?

Yes, I already have an appointment scheduled.No, I have not scheduled yet.
Should be Empty:

New Patient Registration

New Patient Information

Second New Patient Information