Lake Side Animal Hospital of Tilton
Pet Parent Registration Form
Pet Parent Name
*
First Name
Last Name
Pet Parent Phone Number
*
Please enter a valid phone number.
Would you like to receive text message appointment/ health service reminders?
Yes
No
Email
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Contact Name
Relationship
First Name
Last Name
Secondary Contact Phone Number
Please enter a valid phone number.
Client/Owner Date of Birth
Date of Birth
*
Signature
*
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What pet are you bringing in?
*
Pet Name
What type of animal/species are they?
*
What breed are they?
What is their estimated age or date of birth?
*
What color are they? Do they have any special markings?
*
What is their gender?
*
Unknown
Neutered Male
Spayed Female
Intact Male
Intact Female
Who is/was your primary vet?
*
N/A if none
Payment is due at time of service. Acceptable forms of payment are cash, Debit, Visa, Mastercard, Discover, and Care Credit. We do not accept personal checks.
*
I understand
We are not able to offer payment plans at this time, but we do accept third-party payment options with Care Credit. This would allow you to start treatment today, and spread payments over time. Applying for Care Credit only takes minutes and there is no fee to apply.
*
I understand
The undersigned acknowledges and has read and understand our Billing policies.
*
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