Client Registration Form

Client Registration Form
Thank you for giving us the opportunity to care for your pets. So that we may be better able to meet your needs, please complete the following information

**Please note that any co-owners listed on the account are authorized to make medical decisions, including end of life decisions.**
Owner's Name*

First NameLast Name
DOB

MonthDayYear
Date
Spouse/Co-Owner

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Phone Type?

HomeCellWork
Email*
example@example.com
Best Method of Contact

PhoneEmailText
How did you find out about our hospital? (Check all that apply.)

Current ClientLocationFacebookInternet SearchReferralInternet ReviewOther
If from a referral, who may we thank?
If from a website, please specify what site?
Photo Consent:We love social media! Do we have your permission to share your pet’s image and story on social media, our website & other forms of related media? Your name and personal information will never be shared.

Yes. I authorize MVAH to share my pet’s photo & storyNo. I do not authorize this.
Boarding Facility:

I routinely use the boarding facility listed below for my pet(s).I give permission to MVAH to release any relevant medical information to the boarding facility if necessary.
Facility Name
Facility Phone Number
Please enter a valid phone number.
Consent for Emergencies/Release of Medical Information:

I give permission for the individuals named below to obtain medical information for my pet(s) and to seek emergency treatment for my pet(s) in the event that I am unable to do so. I understand that, as the owner, I am financially responsible for any and all services rendered.
Individual #1 Name

First NameLast Name
Individual #1 Number
Please enter a valid phone number.
Individual #2 Name

First NameLast Name
Individual #2 Number
Please enter a valid phone number.
Terms of Service: PAYMENT IN FULL is required at the time services are rendered. We accept cash, checks, Visa, MasterCard, Discover and Care Credit as forms of payment.*

By checking this box, I, the undersigned, agree to pay for veterinary services in a timely manner. I understand that fees on accounts unpaid after 30 days will be 1.33% per month with a minimum monthly charge of $3.00. I agree to be responsible for payment of all collection and reasonable attorney fees incurred should this account be submitted for collections
Signature*

Clear
Please verify that you are human*
Should be Empty:

Client Registration Form

Boarding Facility:

Consent for Emergencies/Release of Medical Information: