DMVHNewClientRegistration

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Thank you for adding Daisy Mountain Veterinary Hospital as your Other Family Doctor!

If you have not made your first appointment with us, please call (623)551-8387 before completing this form!
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Owner's Name* This field is required.What name would you prefer on your profile?
First Name
Last Name
3
Spouse/Significant Other NameIf your spouse or partner has a different name this allows us to search for either of you on the same account
4
Best Contact Phone Number* This field is required.
Area Code
Phone Number
5
This phone number is a:* This field is required.
Cell Phone Number
Home Phone Number
Work Phone Number
6
Alternate Phone Number
Area Code
Phone Number
7
This phone number is a:
Cell Phone Number
Home Phone Number
Work Phone Number
8
Spouse/Significant Other Phone Number
Area Code
Phone Number
9
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
10
Email address* This field is required.
example@example.com
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Has your pet(s) been seen by another veterinarian before* This field is required.
Yes, and I would like you to collect records from them.
Yes, but I will bring records with me or add them in the next step.
No, my pet(s) have not been seen before or I do not have records.
12
The Veterinarian I have been to before is (name of vet) . Please call them at Area Code Phone Number to collect records for my pet(s).
13
I have records for my pet(s) I can attach here:
Drag and drop files here
Select files to upload
Max. file size: 2.0MB
Cancelof
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How many pets do you have?* This field is required.
I have 1 Pet
I have 2 Pets
I have 3 Pets
I have 4 Pets
I have more than 4 pets
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Pet's Name* This field is required.
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Dog or Cat?* This field is required.
Dog
Cat
Other
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Male or Female?* This field is required.
Male
Female
Other
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Spayed or Neutered?* This field is required.
Yes, my animal has been fixed
No, my animal has not been fixed
Other
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Breed* This field is required.
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Color* This field is required.
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Birth date (best estimate)* This field is required.
Date
Month
Day
Year
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Does this pet have a microchip?* This field is required.
Yes, and I know the number
Yes, but I do not know the number
No, this pet does not have a microchip
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Microchip Number
24
Is this pet on any medications?* This field is required.
Yes
No
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I have a picture of my animal:Upload a jpg, jpeg, png, or gif of your animal for their profile!
Drag and drop files here
Select files to upload
Max. file size: 1.0MB
Cancelof
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Second Pet's Name
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Dog or Cat?
Dog
Cat
Other
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Male or Female?
Male
Female
Other
29
Spayed or Neutered?
Yes, my animal has been fixed
No, my animal has not been fixed
Other
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Breed
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Color
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Birth date (best estimate)
Date
Month
Day
Year
33
Does this pet have a microchip?
Yes, and I know the number
Yes, but I do not know the number
No, this pet does not have a microchip
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Microchip Number
35
Is this pet on any medications?
Yes
No
36
I have a picture of my animal:Upload a jpg, jpeg, png, or gif of your animal for their profile!
Drag and drop files here
Select files to upload
Max. file size: 1.0MB
Cancelof
37
Third Pet's Name
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Dog or Cat?
Dog
Cat
Other
39
Male or Female?
Male
Female
Other
40
Spayed or Neutered?
Yes, my animal has been fixed
No, my animal has not been fixed
Other
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Breed
42
Color
43
Birth date (best estimate)
Date
Month
Day
Year
44
Does this pet have a microchip?
Yes, and I know the number
Yes, but I do not know the number
No, this pet does not have a microchip
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Microchip Number
46
Is this pet on any medications?
Yes
No
47
I have a picture of my animal:Upload a jpg, jpeg, png, or gif of your animal for their profile!
Drag and drop files here
Select files to upload
Max. file size: 1.0MB
Cancelof
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Fourth Pet's Name
49
Dog or Cat?
Dog
Cat
Other
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Male or Female?
Male
Female
Other
51
Spayed or Neutered?
Yes, my animal has been fixed
No, my animal has not been fixed
Other
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Breed
53
Color
54
Birth date (best estimate)
Date
Month
Day
Year
55
Does this pet have a microchip?
Yes, and I know the number
Yes, but I do not know the number
No, this pet does not have a microchip
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Microchip Number
57
Is this pet on any medications?
Yes
No
58
I have a picture of my animal:Upload a jpg, jpeg, png, or gif of your animal for their profile!
Drag and drop files here
Select files to upload
Max. file size: 1.0MB
jpg, jpeg, png, gif accepted
Cancelof
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Medications for Pets:
Pet's Name
MedName
Strength
Prescription
Medication 1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Medication 2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Medication 3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Medication 4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Medication 1
Medication 2
Medication 3
Medication 4
Pet's Name
Row 0, Column 0
MedName
Row 0, Column 1
Strength
Row 0, Column 2
Prescription
Row 0, Column 3
Pet's Name
Row 1, Column 0
MedName
Row 1, Column 1
Strength
Row 1, Column 2
Prescription
Row 1, Column 3
Pet's Name
Row 2, Column 0
MedName
Row 2, Column 1
Strength
Row 2, Column 2
Prescription
Row 2, Column 3
Pet's Name
Row 3, Column 0
MedName
Row 3, Column 1
Strength
Row 3, Column 2
Prescription
Row 3, Column 3
1 of 4
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How did you learn about our clinic?
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When is your appointment scheduled with us??
Date
Year
Month
Day
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Signature* This field is required.
Clear
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Date of Signature* This field is required.
Date
Month
Day
Year
65
Do you qualify for a discount?
Military - Active/Retired
Senior Citizen 60yrs+
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Should be Empty: