Cherokee New Client Registration Form

New Client Registration
Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.

Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.
Owner Information
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email*
example@example.com
Co-Owner's Name & Contact Information
Name

First NameLast Name
Co-Owner Phone
Please enter a valid phone number.
How Did You Hear About Our Practice?

Walked/Drove ByTV/Radio/NewspaperHospital EmployeeGoogle/Bing/YahooCard/Flyer/MailerFacebook/InstagramBoarding/GroomingYelpShelterOther - Hospital/VeterinarianExisting ClientOther - Don't Remember
Which hospital/veterinarian?
Which existing client?
Please use this area to give us any other relevant information about yourself or your family.
Pet Information
Pet Name*
Species*

DogCatRabbitFerretBirdReptileOther
Breed (if known)
Color
Date of Birth or Age (if known)
Gender

Neutered MaleSpayed FemaleMaleFemaleUnknown
Spayed/Neutered*

YesNo
Special Identification (tattoos, microchip, etc.)
Previous Veterinary Practice (if any)
Previous Veterinarian (if any)
Date of Last Vaccines (if known)

MonthDayYear
Date
What vaccines were given at this time?
Is your pet on any medication or supplements?

YesNo
If yes, please list medications(s) and supplement(s).
What food does your pet eat?
Does your pet have allergies or drug reactions?

YesNo
If yes, please list allergies and reactions.
Are there any current or past medical conditions of which we should be aware?

YesNo
If yes, please comment on the condition(s) and indicate if they are current or past conditions.
Please use the following box to give us any other relevant information about your pet.
Photo Consent: We love social media! Do we have your permission to share your pet(s)' image and story on social media, our website, and other forms of related media? Your name and personal information will never be shared. Simply check below to authorize this

Yes, I authorize Cherokee Hospital for Animals to share my pet's photo and story.No, I do not authorize this.
Treatment Consent: I hereby authorize the veterinarian to examine, prescribe for or treat the above described pet(s). I assume responsibility for all charges incurred in the care of this animal. I understand that payment is always due IN FULL at time of service and that a deposit may be required for hospitalization and surgical procedures. I recognize that financial concerns should be discussed PRIOR to examination and treatment. The Cherokee Hospital for Animals staff is happy to provide estimates. I understand that Cherokee Hospital for Animals does not bill. Acceptable methods of payment are cash, personal check, Visa, MasterCard, American Express, Discover, and CareCredit.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

New Client Registration

Owner Information

Co-Owner's Name & Contact Information

Pet Information