New Client/Patient Registration
We look forward to meeting you and your pet!
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is the above number a cell phone?
Yes
No
Cell Phone Number (or secondary number if number above is cell)
Please enter a valid phone number.
Format: (000) 000-0000.
Email address. We require email addresses to email vaccine reminders, appointment confirmations, and important updates such as holiday or weather related closures) If you do not wish for us to email you, please write declined in the space below
*
example@example.com
Is anyone else authorized on your account: can bring pets in, can register new pets, can authorized treatments/services, can discuss your pets medical care with us. If so, please list their name(s) and phone number
Do you have Pet Insurance? If so, name of company and are we authorized to release records to them.
Do your pets board, go to daycare, or a groomer? If so, are we authorized to release vaccine history and/or fecal results to them?
How did you hear about us?
Personal Referral
Social Media
Web Search
Other
If you heard about us from a personal referral, who may we thank?
Pet 1 name
*
Sex
*
Male Neutered
Female Spayed
Male
Female
Unknown
Species
*
Cat
Dog
Rabbit
Ferret
Rodent
Breed- For dog mixed breeds, please list the predominant breed and mix- i.e. Lab mix. For cats if not specific breed, can use DSH (domestic short hair) or DLH (domestic long hair)
*
Color
*
Date of birth or approximate age
*
Please upload a copy of your pets medical record. If you do not have this, please contact your previous veterinarian(s) and ask for them to email full medical records (including Doctor notes) to patientcare@eastsuburbananimalhospital.com. We cannot schedule any appointments until we have a copy of your pets previous medical record.
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Previous Veterinarian/Animal Hospital name?
Do we have permission to contact them for records if not provided above?
What does this pet need an appointment for
Wellness and Vaccine
Non-Urgent Sick Visit
Surgery/Dental
Urgent Care/Emergency (Please note: if your pet needs an urgent or emergency visit, please call us after completing, we most likely will have to refer to a 24 hour emergency hospital if it is not something that can wait until our next available appointment which could be several days/week for a new client appointment)
Pet 2 name
Sex
Male Neutered
Female Spayed
Male
Female
Unknown
Species
Cat
Dog
Rabbit
Ferret
Rodent
Breed- For dog mixed breeds, please list the predominant breed and mix- i.e. Lab mix. For cats if not specific breed, can use DSH (domestic short hair) or DLH (domestic long hair)
Color
Date of birth or approximate age
Please upload a copy of your pets medical record. If you do not have this, please contact your previous veterinarian(s) and ask for them to email full medical records (including Doctor notes) to patientcare@eastsuburbananimalhospital.com. We cannot schedule any appointments until we have a copy of your pets previous medical record.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Previous Veterinarian/Animal Hospital name?
Do we have permission to contact them for records if not provided above?
What does this pet need an appointment for
Wellness and Vaccine
Non Urgent Sick Visit
Surgery/Dental
Urgent Care/Emergency (Please note: if your pet needs an urgent or emergency visit, please call us after completing, we most likely will have to refer to a 24 hour emergency hospital if it is not something that can wait until our next available appointment which could be several days/week for a new client appointment)
Acknowledgment of East Suburban Animal Hospital Policies: If you need to cancel or reschedule an appointment, please call us within 4-6 hours of appointment time. No Show appointments may be charged a no show fee, equivalent to our exam fee of $88.00. Appointments arriving more than 15 minutes late will typically have to be rescheduled. Please arrive promptly for your appointment. Payment is always expected at the time of service. Should you need an estimate for services or products, let us know and one will be provided to you. We accept the following payment options: Cash, Visa, Mastercard, Discover, and American Express. We DO NOT accept Care Credit or Scratch Pay or any other financing options.
*
Next Steps:
Once we receive this registration submission, we will create an account for you. If you did not include records with this registration, we will reach out to see if you have them or who we will be receiving them from. Once records are received, we will contact you to schedule an appointment. Let us know if you have any questions in the mean time! Thanks- Katie Caslow, Practice Manager
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