Zionsville Animal Hospital Registration Form

Zionsville Animal Hospital

Client Registration Form
Your Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Contact

First NameLast Name
Additional Contact

Area CodePhone Number
Name of Previous Veterinary Clinic
Please reach out to your previous vet to have records emailed to us at: info@zionsvilleanimalhosital.com
How did you learn about our hospital?*
Name of individual client or Humane Society? Please skip if not applicable.

Pet Information

Please sign below if you agree:

I authorize Zionsville Animal Hospital to take photos or videos of my pet(s) to use for promotional and/or social media.

If you do not authorize for us to use photos of your pet(s) please write do not agree in the signature line.
Signature*
*Please note that your privacy is important to us. All information received in all forms and through other communication is subject to our Patient Privacy Policy. I authorize Zionsville Animal Hospital to share my pet's information to boarding, grooming, daycare and other animal hospitals to facilitate continuity of care. I authorize the doctors and staff of Zionsville Animal Hospital to provide medical service to my pet(s) and I assume full financial responsibility for those services. Any fees associated with an overdue account, such as collection agency fees, attorney fees or court costs, as well as any charges for a refund check will be the responsibility of the client. I have read and understood the above statements and agree to all terms therein.
Signature*
Date*

MonthDayYear
Date
Should be Empty: