New Customer Registration Form

BRAH New Client Registration

Primary Pet Owner Details
Owner's Full Name *

First Name Last Name
Spouse/Partner

First Name Last Name
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Phone Number *
Please enter a valid phone number.
Cell Phone Number *
Please enter a valid phone number.
Spouse/Partner Phone Number
Please enter a valid phone number.
Primary E-mail *
How did you hear about BRAH? *
Have you already scheduled an appointment with BRAH? *
If you have, what day is your visit scheduled for?

Month Day Year
Please select the date of your pet's upcoming appointment.
I hereby give Braden River Animal Hospital permission to take photographs of my pet for the purpose of posting on Braden River Animal Hospital Facebook, Twitter & Clinic Website. *

Yes, BRAH has permission to photograph my pet(s). No, BRAH does NOT have permission photograph my pet(s).
I assume all responsibility incurred in the care of my animals. I also understand the charges incurred are to be paid in full at the time of service and a deposit may be required prior to Hospitalization. I agree to pay all cost of collection and reasonable attorney’s fees in the event of non payment. I also consent to the full release of medical information and authorize direct payment to Braden River Animal Hospital.

I hereby release and discharge Braden River Animal Hospital from any and all claims arising out of use of photos. I am above the age of 18. I have read the foregoing document and fully understand its contents.

Patient Details

You can enter information for up to (3) pets
Patient Name: *
Species: *
Breed: *
Color: *
Date Of Birth: *

Month Day Year
Please choose an estimate of age if you do not know exact birthdate.
Sex: *
Additional Pet (2):

Please skip if non-applicable
Patient Name:
Species:
Breed:
Color:
Date Of Birth:

Month Day Year
Please choose an estimate of age if you do not know exact birthdate.
Sex:
Additional Pet (3):

Please skip if non-applicable
Patient Name:
Species:
Breed:
Color:
Date Of Birth:

Month Day Year
Please choose an estimate of age if you do not know exact birthdate.
Sex:
Patient's Medical History
Please attach any medical or vaccine history you may have for your pet here:

Cancel of
Previous Vet & Phone: *
Please enter "N/A" if your pet has never been to a vet before.

Braden River Financial Policy
Thank you for choosing Braden River Animal Hospital. Our primary mission is to deliver the best and most comprehensive veterinary care available for your pet. An important part of the mission is making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options. Braden River Animal Hospital requires payment in full at the end of your pet's examination and/or at the time of discharge.

Payment Options:

- Cash, Check, Visa®, MasterCard®, American Express® or Discover Card®

- Convenient Monthly Payment Plans¹ from CareCredit®
- Allow you to begin treatment today and pay over time
- Available for any treatment amount
- Can be used repeatedly - for your entire family - without having to reapply¹
Additional Policy Information:

Braden River Animal Hospital charges $30 for returned checks. For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier.

If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your pet.

By signing below, you agree to the foregoing terms of payment:
I agree to the above terms: *

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BRAH New Client Registration

Patient Details

Additional Pet (2):

Additional Pet (3):

Patient's Medical History

Braden River Financial Policy