Garden State Veterinary Services - Woodbridge
1200 Rt 9, Woodbridge NJ 07095 / Phone: 732-283-3535 / Fax: 732-283-4357 / gsvservices.org
Are you currently at the hospital with your pet?
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YES, I am at the hospital for Emergency Services OR a scheduled Specialist appointment (Internal Medicine, Surgery, Cardiology, Oncology, Neurology)
NO, I am not at the hospital. I am submitting my information in advance of a visit.
Client Registration Form
Client / Owner Name
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First Name
Last Name
Address
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Street Address
Apartment
City
State / Province
Postal / Zip Code
Cell Phone Number
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Please enter a valid phone number.
Home/Alternate Phone Number
Please enter a valid phone number.
Email
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Confirmation Email
example@example.com
Spouse or Authorized Representative
First Name
Last Name
Spouse/Authorized Representative Phone Number
Please enter a valid phone number.
Patient / Pet Name
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Species
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Please Select
Dog
Cat
Other
If other than dog or cat, list type of animal
Breed
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Coat Color
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Sex
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Please Select
Female
Male
Unidentified
Spayed / Neutered
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Please Select
Yes
No
Estimated Age (INDICATE YEARS/MONTHS/WEEKS ETC)
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Birthdate (if known)
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Month
-
Day
Year
Date
Weight (if known)
Name of Pet Insurance Company and Policy (If none, please write N/A)
Name of Patient's Veterinarian or Veterinary Hospital and Phone No. (If none, please write N/A)
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Please indicate below whether you wish to have your pet's medical records released to the veterinarian you have listed on this Registration.
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Please Select
Yes
No
N/A
I authorize release of my pet's medical records to
Consent and Authorization: I hereby represent that I am over the age of 18 and authorize the veterinarian to examine, prescribe for or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid when the services are rendered and that a deposit will be required for treatment. Due to the nature of medical services, I understand that once a service is performed, the fee for that service is non-refundable. Service Charge In the event that this account is placed with an attorney or a collection agency because of an unpaid balance remaining on my pet's account, I hereby agree and promise to pay interest of 1.5% per month of the outstanding balance to be calculated starting from my pet's last date of service. In addition, I also agree and promise to pay a collection fee of $100 or 33% of the total balance due, whichever is greater, upon placement with an attorney or collection agency because of an unpaid balance remaining on my pet's account. In the case of a returned check. I acknowledge that there will be a fee of $35 imposed by and payable to GSVS. By signing my name below I hereby acknowledge the above stated policies
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I understand the terms stated above.
Owner / Authorized Representative Signature
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Printed Name of Signer
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First Name
Last Name
Date
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Month
-
Day
Year
Date
Please verify that you are human
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Submit
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