New Customer Registration Form

Client Details:
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
Occupation/Employer*
How did you hear about us?*
If referral, whom can we thank?
Co-Owner Name

First NameLast Name
Co-Owner Email
example@example.com
Co-Owner Phone
Please enter a valid phone number.
How would you prefer reminders/communications? Check all that apply*

TextPhoneEmail
Do we have your permission to use your pet's photo on social media?*

YesNo

Pet Information

(Please submit an individual form for each pet)
Pet's Name*
Birth Date*

MonthDayYear
Species*
Sex*
Spayed/Neutered?*
Breed*
Color/Markings*
Will your pet attempt to bite if scared?*
Current Medications:*
Current Diet:*
Previous Illness or Surgeries:*
Please list all Previous Veterinary Clinics your pet has been a patient of that we may call for records:*

Please initial the following statements indicating that you have read them, understand them, and agree to them:
Initials* I hereby certify that I am the rightful owner/keeper/caretaker/custodian of the animal(s) who is/are the subject of this New Client Form, hereinafter referred to as “the animal.” I further certify that no other person has a right of property to the animal.
blanks* I understand that I am required to Pre-Pay a non-refundable exam fee before setting up my appointment.
blanks* I understand if I am more than 10 minutes late to my appointment that I will be asked to re-schedule and my Pre-Paid Exam Fee will not be refunded.
blanks* I understand that I am financially responsible for all charges for services rendered and that payment is due at the time of service. Cash or Credit only. No checks please. There are no payment-plan options including CareCredit.
blanks* I agree to pay in full for services rendered, including those deemed necessary for medical and/or surgical complications or unforeseen circumstances at time of discharge.
blanks* Any estimate of charges for presently planned procedures is only an approximation and the final bill may be greater or less than this amount.
blanks* I understand that Bennington Animal Hospital does not communicate with any outside, online pharmacies other than MyVetStoreOnline (MVSO). This practice is to protect your pet and our Hospital from fraud and harm caused by counterfeit products, incorrect substitutions, dosing changes without medical authorization, and many other liabilities than can result in illness or death in your pet. As such, if you choose to fill medications outside of Bennington Animal Hospital or MVSO, you will be required to pick up a written prescription and mail it to the pharmacy of your choice. I also understand that Bennington Animal Hospital charges a nominal fee of $1.00 per written paper script unless it is for a medication not stocked by BAH or MVSO.
blanks* I am aware that a deposit may be required at the time of admission for surgical, drop off examinations and emergencies.
blanks* I further understand should my account become delinquent; I shall pay all reasonable fees or collection fees, if any.
blanks* Balances due over one day will be charged $25 a day until paid in full, unless arrangements have been made with Drs. Nickerson. Unpaid bills over 30 days will be brought to small claims court for theft of services.
blanks* In order to keep our hospital disease free, we ask that your pet be current on Heartworm and Flea/Tick medications. If any external or internal parasites are found while your pet is in our care, we will treat them appropriately, unless pets’ illness deems otherwise. This treatment will be at the owner’s expense. All pets must be up to date on Rabies and Distemper/Parvo vaccines or provide us with proof.
blanks* I understand that I am responsible for the energy that I bring into this space. Bennington Animal Hospital is a private entity and reserves the right to permanently dismiss any client for belligerent or otherwise rude behavior towards any member of their staff.
blanks* "Clinic Hopping" is a dangerous practice and can have disastrous effects on the animal's health if various practitioner's are unaware of recently-performed treatments or medications administered. As such, if you request for your records to be sent to another practice excluding emergent or speciality care, Bennington Animal Hospital reserves the right to terminate the previously-establish Client-Patient relationship with you.
I further certify that I have read and understand the terms of this New Client Form*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Client Details:

Pet Information

Please initial the following statements indicating that you have read them, understand them, and agree to them: