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*
Format: (000) 000-0000.
E-mail*
Occupation/Employer*
We support LOCAL also! If you own/work for a small business, please let us know the name of it and we will use your services as well:
How did you hear about us?*
Please specify if you marked 'Other'
Please specify here if you marked 'Other' or Referral above:

blanksblank
If Referral from current client, please list them here:

First NameLast Name
Co-Owner Name

First NameLast Name
Co-Owner Email
example@example.com
Co-Owner Phone
Please enter a valid phone number.Format: (000) 000-0000.
TextPhoneEmail
YesNo

Pet Information

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

MonthDayYear
Species*
Sex*
Spayed/Neutered?*
Breed and 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:*
Are there other pets you would like to transfer to BAH? If so, please list them here*
What is important to you when considering a new veterinary practice for your pet? *

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 Annual 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 deposit to be used for the exam fee before setting up my appointment. If I cancel within 24 hours or do not show up for the appointment, this fee is non-refundable.
blanks* I understand if I am more than 10 minutes late for my appointment that I will be asked to reschedule.
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 BAH does not communicate with any outside, online pharmacies other than 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 that can result in illness or death in your pet. As such, if you choose to fill medications outside of BAH or MVSO, you will be required to pick up a written prescription and mail it to the pharmacy of your choice. There is a nominal $1.00 charge per written script unless the medication is not carried 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 am aware that BAH does not get involved in breeding pets. This includes but is not limited to: artificial insemination, pregnancy checking, labor, delivery, complications, and C-sections. If I choose to breed my pet, I will be referred out to Hillcrest Animal Clinic in Lincoln, NE.
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* Our veterinary services utilize ScribbleVet, which records your pet's appointments for improved clinical documentation. By initializing here, you agree that your vet appointments may be recorded and you grant us permission to share these recordings, and any other materials you choose to provide, for the purpose of improved clinical documentation.
blanks* I understand and agree that BAH reserves the right to temporarily or permanently dismiss me and my pet(s) at any time BAH determines, in its sole discretion, that continuing to provide veterinary services to my pet(s) is not in the best interest of me, my pet(s), or BAH. BAH shall not be obligated to provide me or anyone else acting on my behalf an explanation of the basis for such dismissal.
blanks* "Clinic hopping" is a dangerous practice and can have disastrous effects on the animal's health if various practitioners are unaware of recently-performed treatments or medications administered. As such, if you receive vaccines, surgery, or other medical care at another practice (excluding emergent or specialty care), BAH reserves the right to terminate the previously-established client/patient relationship with you to protect our liability.
I further certify that I have read and understand the terms of this New Client Form*
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: