New Client/Pet Registration Form

New Client/Pet Registration Form
Laveen Veterinary Center

7700 S. 43rd Avenue

Laveen, AZ 85339

Phone: 602-559-9600

Email: office@laveenvetcenter.com
Client Information
Primary Owner Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Email Address*
example@example.com
Co-owner Name

First NameLast Name
Co-owner Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Co-owner Email Address
example@example.com
Additional Responsible Party

First NameLast Name
Owner; Co-owner and Additional Responsible Party must be 18 years of age or older.
How did you hear about us?
Yes. I authorize Laveen/Phoenix Veterinary Center to share my pet's photo and story.No. I do not authorize Laveen/Phoenix Veterinary Center use of my pet's photo and story.
We do not carry open accounts.
- Owner agrees to pay any costs and attorney's fees necessary for the collection of any amount not paid when due.
- Full payment is required at the time of service. Deposits are required on major medical/surgical cases, trauma cases and hospitalization. We offer Care Credit as a method of making payment. Please ask about these options before services are provided.
- We accept local checks only; no out of state checks will be accepted. We will ask for your driver's license every time you write a check. This hospital works in conjunction with the County Attorney's office in reporting all bad check writers.
- For security purposes and to protect the personal information of our clients, we will not keep credit card information on file.
I understand Laveen Veterinary Center and Phoenix Veterinary Center are NOT 24 hour facilities.

Beyond hours of operation, no staff will be on the premises to monitor animals.
Cancellation Policy

To better serve our patients, Laveen Veterinary Center and Phoenix Veterinary Center require a 24 hour notice for any cancjellation or rescheduling of appointments. If you arrive more than 15 minutes after the appointment time, we may need you to reschedule. Prepayment for services will be required after 3 violations of this policy. This includes failure to show for the appointment and late arrival reschedules.
Please initial that you have read the above statement on the above policies: Type a label*
Patient Information
Pet Name*
CatDog
Breed*
MaleFemaleMale NeuteredFemale Spayed
Pet's Age*
Pet's Color*
Previous Medical Problems*
Current Medical Problems*
List of Current Medications - Dose - Frequencies*
Where can we obtain your pet's vaccination history and previous records? *
YesNo
Primary Owner's Signature*

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Primary Owner's Name (Print)*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

New Client/Pet Registration Form

Client Information

Patient Information