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
I confirm I am over 18 years of age.
Spouse/Co-Owner

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type?
Email
example@example.com
Best Method of Contact
How did you find out about our hospital? (Check all that apply.)

Other
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.
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.Format: (000) 000-0000.
Consent for Emergencies, Treatment, Release of Info & End-of-Life Care

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.Format: (000) 000-0000.
I authorize the person named above to make medical decisions, including end of life decisions for my pets.
Individual #2 Name

First NameLast Name
Individual #2 Number
Please enter a valid phone number.Format: (000) 000-0000.
I authorize the person named above to make medical decisions, including end of life decisions for my pets.
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.
Signature
Please verify that you are human
Should be Empty:

Client Registration Form

Boarding Facility:

Consent for Emergencies, Treatment, Release of Info & End-of-Life Care