Client Registration

Registration Form

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have any questions, please feel free to ask one of our staff members.
Primary Owner Name*

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Employer
Employer Phone Number

Area CodePhone Number
Spouse/ Alternate Owner
Address (if different from Primary Owner)
Phone Number
E-mail
Notify in case of Emergency*
Emergency Phone Number*

Area CodePhone Number
How did you hear about us?*
If referred by HVC client, please provide his/her name
Media Release: I give my permission for my pet's FIRST name and photograph to be used on HVC's website, facebook page, and within the clinic.

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Financial Responsibility Agreement

Payment is due at the time services are rendered. In cases of extensive medical or surgical procedures, where full payment may be difficult at discharge, we accept all major credit cards and Care Credit.

I, the undersigned, assume full responsibility for all charges incurred in the care of my animals. I also understand that these charges will be paid at the time of release and that a deposit may be required for treatment. There will be a service charge of $30.00 for any check returned unpaid. If for any reason my bill is not paid at the time of service, I understand my account may be susceptible to interest fees, collection fees, and/or attorney's fees, and any court costs required to collect on my account.

Please sign below.
Financial Responsibility Agreement SIGNATURE *

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Should be Empty:

Registration Form