New Client Registration Form

We are currently only accepting new clients for non- urgent visits to establish patient care. This questionnaire consists of 1 page used to collect information needed by the doctors and staff at The Aurora Veterinary Clinic, Streetsboro Veterinary Center and Mantua Veterinary Clinic in order to provide the best care for our patients. During your first visit, we will confirm all of this information with you.

Please answer the questions to the best of your ability.

Name*

First NameLast Name

Today's Date *

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Additional Account Name (i.e. spouse/ partner)

First NameLast Name

Phone Number (i.e. spouse / partner)

How did you hear about us?

Email*

example@example.com

Do you already have an appointment? *

If referral/ other, please specify:

Pet's name*

Pet species*

Pet breed*

Pet color*

Pet Birthdate, if known

Date

Pet age (best guess is fine)*

How long has your pet lived with you?

Where did you obtain your pet?

What is the gender of your pet? Spayed or neutered? *

**Please note: If your pet is coming in for a second opinion, please ensure the previous records have been received by our clinic within 48 hours of your appointment. If records have not been received from you or the previous veterinary facility within 24 hours of the appointment, the appointment will need to be rescheduled.**

Medical history:

Chronic conditions, allergies, medications, supplements

Any medical records can be emailed to auroraveterinary@gmail.com. Please provide us the name, phone number, city and state of your pet's previous veterinary clinic and phone number. If your pet hasn't been to a veterinary clinic yet, please bring any previous records with you to their appointment or upload in the section below.

Do you have insurance for your pet? If so, please provide insurance name:

Mutual Respect Agreement:

I understand that Aurora Animal Care Center is a healing environment, and respectful communication and collaboration between our team members and you, our client, is essential to provide optimal patient care. I understand that just as I would expect empathy, patience, honesty, and kindness from the team at AACC, our team is deserving of the same.

There is ZERO TOLERANCE for all forms of aggression and disruptive behavior both verbal and physical. Such behavior will result in termination of the veterinary-client-patient relationship.

Select to agree: *

I understand and agree to abide by the Client Code of Conduct

I am the owner and hereby authorize the veterinarian to examine, prescribe for or treat the above-described pet(s). I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges must be paid in full, at the time of release of the pet.

Signature:*