New Client Registration Form

Name*

First NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Home NumberCell NumberWork Number
Spouse
Best Phone Number to Reach Spouse
Please enter a valid phone number.Format: (000) 000-0000.
Driver’s License number*
State*
Owner’s Birth Date*

MonthDayYear
Date
Birthday is required per California Dept. of Justice / Bureau of Narcotic Enforcement to dispense any Schedule II, III and IV medications to your pet.
YesNo
FriendVeterinarianPet BusinessBay Animal Hospital’s WebsiteGoogleFacebookYelpNextdoorOther
Pet Information
Name*
Species*
Breed*
MaleFemale
YesNo
Date of Birth*

MonthDayYear
Date
Color*
YesNo
Name*
Species*
Breed*
MaleFemale
YesNo
Date of Birth*

MonthDayYear
Date
Color*
YesNo
Name*
Species*
Breed*
MaleFemale
YesNo
Date of Birth*

MonthDayYear
Date
Color*
YesNo
Name*
Species*
Breed*
MaleFemale
YesNo
Date of Birth*

MonthDayYear
Date
Color*
- I hereby authorize Bay Animal Hospital to render surgical and medical care for my pet(s) as deemed necessary by the veterinarian.
- I understand that payment is required in full at time of discharge.
- I understand I may be asked to leave a 50% down payment before surgical procedures and that no guarantee can be given to the outcome.
- I understand that Bay Animal Hospital does not accept checks or offer payment plans. If you require a payment plan please ask the Receptionist for a Care Credit application and brochure. Care Credit is a 6 month no interest medical credit card.
- Veterinary service during nighttime hours, some daytime hours, and/or weekends, is provided at the discretion of the veterinarian in charge. Continuous presence of personnel may not be provided during these hours.
- I understand personal items (blankets, toys etc.) may not be returned if left at Bay Animal Hospital.
- I understand that fecal testing is recommended every 6 months for my pet and according to the Centers for Disease Control and Prevention, dog and cat parasites can be transmitted to humans and can cause potentially serious health problems.
- I understand that eliminating intestinal parasites from my pet is essential and is extremely important for the health of my family.
I have read and understand the above statements and authorize Bay Animal Hospital to render surgical and medical care for my pet(s) as deemed necessary by the veterinarian.
Date*

MonthDayYear
Date
Signature*

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Pet Information