Three Springs Animal Hospital New Patient Registration
Please complete this form to help us provide the best care for your pet. All sections are required for registration.
WELCOME TO THREE SPRINGS ANIMAL HOSPITAL
Thank you for giving us the opportunity to care for your pet. We’ll be happy to answer any questions you have about your pet’s health. To ensure the best care possible, please take the time to fill in this form completely. Thank you!
Registration
Owner
*
Email
*
example@example.com
Address
*
City
*
State
*
Zip Code
*
Home Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Spouse
Spouse Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Spouse Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Employer’s Name & Address (Owner)
Employer’s Name & Address (Spouse)
How did you hear about our hospital?
Yellow Pages
Hospital Sign
Recommendation
Other
If recommended, by whom?
Are any of your pets microchipped?
Pet Health History
Name of Pet
*
Species
*
Dog
Cat
Other
Other Species
Sex
*
Male
Female
Age
*
Birthdate
-
Month
-
Day
Year
Date
Breed
Color
Neutered/Spayed
YES
NO
What age was pet obtained?
From
Friend
Breeder
Pet Store
Humane Society
Other
Vaccination History (check all that pet has received)
Distemper (Dog)
Parvovirus (Dog)
Kennel Cough/Bordetella (Dog)
Feline Leukemia Vaccine
Feline Leukemia Test
FVRCP (Infectious Disease – Cat)
Fecal Check (Dog/Cat)
Rabies (Dog/Cat)
Heartworm Test (Dog/Cat)
Please check any symptoms or problems you’ve noticed with your pet.
Appetite Loss
Behavioral Changes
Breathing Problems
Coughing
Depression
Diarrhea
Eye Disorders
Gagging
Gums Bleeding
Limping
Loss of Balance
Scooting
Scratching
Shaking Head
Sneezing
Thirst
Urination Increase
Vomiting
Weakness
Other
Eye Disorders
Other Symptom 1
Other Symptom 2
Method of Payment
Cash
Check
Credit Card (AMEX, MC, Visa, or Discover)
Authorization
In the event that charges incurred are not paid in full at time of service and collection action is instituted within 90 days, whether by a collection agency, attorney or both, I agree to be responsible for and to pay, in addition to the charges for services, treatment and goods received, all costs associated with such collection activity including but not limited to reasonable interest, collection agency fees, attorney fees and court costs. You agree to reimburse us the collection fees of any collection agency, which shall be based on a percentage at a maximum rate of 33 1/3% of the amount due at the time your account is placed with collection agency, and all costs and expenses incurred for any collection efforts on your account, including reasonable attorney’s fees incurred by the collection agency. This contract shall cover all medical treatments and services until revoked by either party in writing. I grant Three Springs Animal Hospital permission to post my pet’s picture, name, and story to social media, TSAH website, and use for marketing purposes.
Signature of Owner
*
Date
*
-
Month
-
Day
Year
Date
Preferred Method of Payment
*
Cash
Check
Credit Card (AMEX, MC, Visa, or Discover)
Submit Registration
Submit Registration
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