5541 Main St
williamsville@buffaloveterinarygroup.com
www.williamsvilleveterinaryhospital.com
716-817-8171
New Client Information:
Owner Name
*
First Name
Last Name
Co-Owner Name
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
Format: (000) 000-0000.
Home Phone Number
Format: (000) 000-0000.
Co-Owner Cell Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Preferred method of contact?
*
Please Select
Cell Phone
Home Phone
Email
Patient #1 Information:
#1 Pet Name:
*
Name
#1 Pet Breed/Color:
*
Breed
Color
Pet's Date of Birth:
*
-
Month
-
Day
Year
Date
Please check here if DOB is estimated:
Estimated
Sex:
*
Male
Female
Is your pet spayed/neutered?
*
Yes
No
Is your pet microchipped?
Yes
No
Patient #2 Information:
Please skip if only registering one pet.
#2 Pet Name:
Name
#2 Pet Breed/Color:
Breed
Color
Pet's Date of Birth:
-
Month
-
Day
Year
Date
Please check here if DOB is estimated:
Estimated
Sex:
Male
Female
Is your pet spayed/neutered?
Yes
No
Is your pet microchipped?
Yes
No
Previous Records:
Has your pet been to another veterinarian?
*
Yes
No
Name of Veterinarian/Hospital:
Name
What medications or supplements is/are your pets receiving?
Please describe medications or other supplements, if applicable.
Do you have health insurance for your pet(s)?
*
Yes
No
If yes, who is the provider?
Referrals:
Referrals are appreciated, and we will place a credit on their account as a thank you. Were we recommended to you by another client?
*
Yes
No
If yes, who may we thank?
Name
Social Media Release:
Within the context of promoting our business and pet health, we would like to use images, videos, and/or information about your pet on our social media sites. Do you wish your pet to participate on our social media sites?
*
Yes
No
Payment policy
We accept cash, Mastercard/VISA/Discover/American Express and CareCredit. Payment is expected when services are rendered. We will gladly prepare you a written estimate of services prior to the treatment of your pet if you desire. I realize and understand that I am financially responsible for the care and treatment of my pet(s). I further agree that in the case of non-payment, a finance charge or interest fee and collection fees will apply.
Signature
Submit
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