New Client Registration

New Client Registration
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*
Secondary Phone
Email*
example@example.com
Driver’s License Number*
Date*

MonthDayYear
Any additional person(s) authorized to make financial/medical decisions on this account
May we post photos of you or your animals on our social media pages? *
How did you hear about Memorial Animal Hospital?*

Google searchFriends/FamilySocial MediaDrove byOther
Please read the following thoroughly

By signing below I authorize the veterinarians at Memorial Animal Hospital to examine, prescribe for, and treat any of my pets. I assume responsibility for all charges incurred in the care and/or treatment of animals listed under my account. I also understand that all professional fees are due at the time of services rendered and that Memorial Animal Hospital may charge a fee for any missed or late appointments. A copy of our “No-Show Policy” is available upon request. Accepted methods of payment are Visa, Mastercard, Discover, American Express, Care Credit, cash, check (DL required) and/or a combination thereof. I understand that if there is an unpaid balance on my account, Memorial Animal Hospital reserves the right to apply finance charges to my account balance monthly, can refuse to perform elective services for my pets and may send my account to collections.
Signature*

Clear
Date*

MonthDayYear
Should be Empty:

Please read the following thoroughly