New Client Registration Form

CLIENT REGISTRATION

Welcome to The Drake Center!
Thank you for giving us the opportunity to care for your pet. So that we may become better acquainted, please complete the following information.
Pet owner's name*
Pet owner's date of birth*
Spouse/co owner's name
Mailing address*
City*
State*
Zip*
Telephone Number - Please circle one: Cell / Home / Work*
Email Address*
example@example.com
How may we contact you?*

Telephone: Which number do you prefer (Owner or Co-owner's)?Text message (Please list preferred number if different from number listed above)Owner's EmailCo-owner's Email (Optional)
Please specify preferred contact method:
Previous veterinarian
How did you hear about us?*

Personal Recommendation (Please specify below)Drive by/signageNew homeowner letterAdvertisementSearch engine (Google, Yahoo!, Bing, Etc.) Please Specify below:Event (Please specify):Local news (Please specify):Website (thedrakecenter.com):Social Media (Facebook, Instagram, Yelp!, Nextdoor, etc.) Please specify:Shelter recommendation (Please specify):Other (Please specify)
Please specify how you heard about The Drake Center*
May we share photos of your pet on our website and/or Facebook page?*

YesNo
Please tell us about your pet(s). For our records, we ask that you list every pet, even if they are not being seen today.
Pet's Name:*
Species:*
Breed:*
Sex:*

MaleFemale
Spayed/Neutered:*

YesNo
Date of birth*

MonthDayYear
Date
Color:*
Second Pet's Name:
Species:
Breed:
Sex:

MaleFemale
Spayed/Neutered:

YesNo
Date of birth

MonthDayYear
Date
Color:
Third Pet's Name:
Species:
Breed:
Sex:

MaleFemale
Spayed/Neutered:

YesNo
Date of birth

MonthDayYear
Date
Color:
Professional fees are due at the time services are provided. We offer Care Credit services as well as payment plans for those wishing to apply. Please let us know if you would like an application for either of these programs.

We accept the following credit cards for your convenience: Visa, MasterCard, American Express and Discover.
Signature of Pet Owner*

Clear
Date*

MonthDayYear
Date
Should be Empty:

CLIENT REGISTRATION