SouthPark Animal Clinic New Client Registration
Name of person responsible for medical and financial decisions for your pets.
*
First Name
Last Name
Spouse/Partner Name - Anyone authorized to make medical or financial decisions for your pets.
First Name
Last Name
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Primary Phone Number
*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Email Address
*
example@example.com
Back
Next
Emergency Contact Name: Person(s) authorized to make medical and financial decisions about your pets if we are unable to reach your during an emergency.
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Back
Next
How Did You Hear About Us?
Name of Friend We Should Thank For the Referral - We want to make sure they receive credit for sharing our information with you.
Back
Next
Pet's Name
*
Species- Dog, Cat, Bird, etc.
*
Pet's Sex
*
Male
Female
I don't Know
Is Patient Altered or Unsexed?
*
Spayed
Neutered
Neither
I Don't Know
Patient's Breed
*
What Color is Patient?
*
Patient's Age - Please provide approximate age or exact date of birth if you know it.
*
Back
Next
Any Other Pet's you would like on your account? Please Include: Name Male/Female Spayed/neutered/intact/unknown Cat, dog, rabbit, etc Breed Age Color
Back
Next
Has your pet been seen at a different clinic?
Yes
No
If Yes, Please list ALL clinics we will need to call for records. Please provide any different names they may be listed under if applicable.
Back
Next
We want your pet to be Facebook Famous, but we need your permission first. I grant permission to SouthPark Animal Clinic, it's employees and authorized representatives to take photographs and/or video of me and/or my pet(s), to copyright, use and publish the same in print and/or electronically. SouthPark Animal Clinic may also use and publish my pet's story, including relevant medical history. I agree that SouthPark Animal Clinic may use such photographs, videos or stories including me and/or my pet with or without our names and for any lawful purpose, including for example such purposes as social media, publicity advertising, and other web content.
*
I Accept
I Don't Accept
Does Your Pet Have Their Own Instagram or Facebook Account? Please list all of them so we can connect!
Back
Next
At SouthPark Animal Clinic, our top priority is providing excellent quality care for your pet. We realize that finances to provide that care may be a concern and we are committed to providing options that make veterinary care more accessible. PAYMENT IS DUE AT TIME OF SERVICE. IF YOU ARE UNABLE TO PAY TODAY, PLEASE DISCUSS OPTIONS WITH OUR STAFF PRIOR TO YOUR APPOINTMENT. Payment types accepted: cash, checks, Visa, Mastercard, Discover, American Express, Carecredit. Carecredit MUST BE APPROVED IN ADVANCE of any services rendered. A$20 fee will be assessed for any returned checks.
*
I Accept
I Do Not Accept
We provide written treatment plans for any procedure UPON REQUEST. Treatment plans approximate total costs as closely as possible, however the final invoice may vary from the treatment plan. Treatment plan is only valid for 30 days. Deposits may be required for ALL anesthetic procedures or any extensive care, for up to 75% of estimated costs for treatment. The remaining balance will be due at the time of discharge from the hospital.
*
I Accept
I Do Not Accept
Submit
Should be Empty: