Urgent Care Patient Registration Form

Urgent Care Patient Registration Form
Primary Veterinary Practice*
Primary Owner/Agent Name*

First NameLast Name
Primary Communication Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Additional Owner/Agent

First NameLast Name
Additional Owner/Agent Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about us?*

VeterinarianFacebookInstagramInternetRescue/Humane SocietyWord of MouthBusiness/Other
Pet Name*
Species*
Breed*
Birthday*

MonthDayYear
Date
Age*
in Years
Color*
Gender*
Known Allergies?*
*

By submitting this form, I confirm and agree that I am the legal owner or authorized agent of the above mentioned pet. I understand that payment for all services rendered is due at the time of treatment or when services are provided. Forms of payment accepted: Cash, Visa, Mastercard, Discover, Amex, and bank debit cards.I understand the examination and treatment my pet receives is rendered on an urgent basis only. It is not intended to be a substitute for, or an effort to provide complete veterinary care. Please follow up with your primary veterinarian for long-term care of your pet.
If you do not wish for your pet’s photos/videos to be shared on social media, please let us know that you wish to opt-out and we will note your pet’s record.
*

ApprovedOpt-Out
Reason for Visit*
A member of the UPP team will verify your photo identification matches your name as listed above. Please have your photo ID available.
Signature*
Today's Date*

MonthDayYear
Date
Authentication Check*
Should be Empty: