Client Registration Form

Thank you for giving Four Corners Veterinary Hospital the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following:

New Clients: If you are new to Four Corners Veterinary Hospital please fill out the Client Registration Form and submit it as soon as possible. Once we receive your form(s) one of our Client Service Representatives will call you to schedule your first appointment.

New client appointments can not be booked until we receive the completed form(s).

Client #

To be completed by FCVH staff

Primary Owner's Birthdate *

Date

Primary Owner's Name *

First Name Last Name

Primary Owner's Email *

example@example.com

Primary Owner's Cell Phone *

Please enter a valid phone number.

Primary Owner's Home Phone

If same as cell please re-enter cell number

Primary Owner's Work Number

Please enter a valid phone number.

Please note which number you would like to be the primary contact number for this account *

Primary Owner's Address *

Street Address

Street Address Line 2

City State

Zip Code

Primary Owner's Driver License Number *

State *

Do you consent to receiving drug information via email/text should your pet receive any prescriptions *

If you agree, do you prefer Text or Email *

At FCVH we love our patients and sometimes we would like to share their photos on our social media sites, website, print or other advertising. Do you consent to having your pet(s) picture used for these purposes? *

Emergency Contact or Co-Owner

First Name Last Name

Emergency Contact or Co-Owner Phone Number

Please enter a valid phone number.

Do you authorize the Emergency Contact/Co-Owner to make medical or financial decisions regarding your pet(s) care while staying at FCVH, if you are unreachable? *

How did you hear about our hospital? *

If referral or other please list name

Has your pet(s) been seen by another veterinary hospital in the past? If so please provide veterinary records by email to info@fourcornersvet.com or fax at 925-685-7152 within 24 hours of submitting your New Client Application. First appointments will not be scheduled without prior records *

If yes, please list hospital who will be sending prior records.

Please review and agree to all terms below. If you do not agree with all terms we will be unable to schedule an appointment for you at this time. If you have any questions you may email info@fourcornersvet.com attention Hospital Manager.

For more information, please ask to speak to our Hospital Manager directly or by emailing info@fourcornersvet.com to further address an issue.

Signature *

Clear

Date *