Client/Patient Registration Form

Client/Patient Registration Form
I certify that I am the owner/guardian of the below-mentioned animal. I hereby authorize the staff of Emergency Veterinary Services to examine my pet. I also authorize recommended testing, treatment, medications, or surgery after consultation with me by the staff of Emergency Veterinary Services.

I assume full financial responsibility for all charges incurred for the exam/services/treatment/ medications provided by Emergency Veterinary Services. I understand that the entire balance must be paid in full at the time of discharge, billing is not available. If my pet requires hospitalization, I will be provided with an estimate. A deposit of the low end of the estimated charges will be required at admission.
Owner's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number*

Area CodePhone Number
Home Number

Area CodePhone Number
Email*
example@example.com

Account Information
Method of Payment*
How Did You Hear About Us?*
I certify that I am the owner/gaurdian of the above mentioned animal. I hereby authorize the staff of Emergency Veterinary Services to examine my pet. I also authorize recommended testing, treatment, medications, or surgery after consultation with me by the staff of Emergency Veterinary Services.

I assume full financial responsibility for all charges incurred for the services/treatment/medications provided by Emergency Veterinary Services. I understand that the entire balance must be paid in full at the time of discharge, billing is not available. If my pet requires hospitalization I will be provided an estimate. A deposit for the low end of the estimated charges will be required at admission.
Date*

MonthDayYear
Date
Client Signature*

Clear
Should be Empty:

Patient Information