Hopewell Junction: New Specialty Client Registration Form of Hudson Highlands Veterinary Medical Group

New Specialty & Orthopedic Client Registration Form

Please Submit BEFORE Your Appointment
Client Name: *
Co-Owner/Spouse/Partner’s Name:*
Address*

Street Address Line 2
Employer
Primary Contact #*
Format: (000) 000-0000.
Select Phone Type

CellHomeWork
Name*
Contact #2
Format: (000) 000-0000.
Select Phone Type

CellHomeWork
Name
Contact #3
Format: (000) 000-0000.
Select Phone Type

CellHomeWork
Name
Email:*
Email is used as a direct means of communication by many of our specialists.
Patient Information
Pet Name
Pet

DogCat
Sex

MaleFemale
Spayed or Neuter

YesNo
Breed
Date of Birth

MonthDayYear
Color/Markings
Current Weight:
Medical History/Referring Issue
Were you referred to one of our specialists by another veterinarian?

YesNo
Referring Doctor
Would you like a report sent to your regular veterinarian?

YesNo
Regular Doctor:
If not referred by a veterinarian, how did you hear about our practice?*

Internet SearchFacebookWebsiteFriend or RelativeOther
If so, their name is
I, the undersigned, understand and agree that payment is due as services are rendered. If for any reason an unpaid balance remains on my account, after 30 days a finance charge will be applied. The finance charge is computed by a periodic rate of 1.75% per month, which is the annual percentage rate of 25%. I am also aware that if this account should be come delinquent, the same shall be responsible for the collection agencies fees. A $15.00 fee will be charged for each returned check.
Owner's Signature*
Date*

MonthDayYear
Should be Empty:

New Specialty & Orthopedic Client Registration Form

Patient Information