New Client Registration Form

Primary Owner's Name *

First Name Last Name

Secondary Owner's Name

First Name Last Name

Address *

Street Address

Street Address Line 2

City State

Zip Code Country

Primary Phone *

Area Code Phone Number

Primary Phone is:

Ex. Home

Secondary Phone

Area Code Phone Number

Secondary Phone is:

Ex. John Smith's cell

Alternative Phone

Area Code Phone Number

Alternative Phone is:

Ex. John Smith's work

E-mail *

Pet #1

Pet's Name *

Species *

Color *

Breed *

Sex *

Female/Spayed Male/Neutered Female/Intact Male/Intact Unknown

Age *

Year(s)

Months

Month(s)

DOB

Date

Microchip

Microchip Number

Picture of Pet

Browse Files

Pet #2

Pet's Name

Species

Color

Breed

Sex

Female/Spayed Male/Neutered Female/Intact Male/Intact Unknown

Age

Year(s)

Months

Month(s)

DOB (if known)

Date

Microchip

Microchip Number

Picture of Pet

Browse Files

Pet #3

Pet's Name

Species

Color

Breed

Sex

Female/Spayed Male/Neutered Female/Intact Male/Intact Unknown

Age

Year(s)

Month(s)

DOB (if known)

Date

Microchip

Microchip Number

Picture of Pet

Browse Files

Pet Insurance

Insurance

Insurance Name

Policy Number

Pet #1

Policy Number

Pet #2

Policy Number

Pet #3

Previous Veterinary Care

Name of previous veterinary care facility

ex. Gateway Pet Hospital

City & State

ex. San Ramon, CA

Phone Number

ex. (925) 560-9622

Can we contact the previous veterinary care facility for your pet(s) records?

Yes, please get my pet(s) records No, I have copies of my pet(s) records

How did you schedule your appointment?

Called the office Online Appointment Request Emailed Walked in

How easy was it to schedule your appointment?

Friendliness of Staff

Overall experience

How can we make all future visits pleasurable for you and your pet(s)?

How did you hear about us?

Comments

Appointment Policy

To allow ample time for all patients and scheduled surgical procedures, we operate primarily by appointment. Emergency cases shall always receive top priority, which is why occasional appointment delay is inevitable. Please realize that we make a sincere attempt to see each client on time.

If an appointment is not available, "drop-off' appointments are available. A drop off means you could bring your pet at the time that works best for you and board him/her with us for part of the day. (Please note that there is a fee for day boarding.) Usually we will ask you to drop off' sometime in the morning so our doctors can examine the patient in between appointments or at the time purposely reserved for admitted patients. Once the doctor is done, we will give you a call to go over the diagnosis and to give you discharge instructions.

Cancellation Policy

Our goal is to keep our appointments available for our patients that need medical attention. For this reason it is important that we be notified of any cancellations ASAP. (The more notice we have, the more time that gives us to call clients waiting for an opening and allow them to adjust their schedules.) Clients calling after their appointment, or who miss their appointment, will be reminded about our policy. A second missed or "late" cancellation will result in the client being asked to pay a $20 deposit fee when scheduling future appointments which will be applied to their account as a credit toward their next visit. If that next visit is missed or has a “late” cancellation, the $20 appointment credit will then become a non-refundable cancellation fee.

We hope you understand the need for this policy and thank you for allowing us the opportunity to take care of your pet's healthcare needs.

Return Policy

Just like with a human pharmacy, products that have left our facility cannot be returned. However, opened bags of dog and cat food may be returned or exchanged because they are guaranteed by the manufacturer.

Patient Arrival Policy

For your protection, and that of others, all dogs must be on a leash and
properly controlled while in the waiting area or exam rooms.

All cats must be presented in an appropriate cat carrier.

Payment Policy

Communications regarding finances is extremely important for good relations between client and staff. At the time of admission of a pet to the hospital we communicate with the client by giving an estimate of expected fees. Please communicate with us any problem you might have with paying your bill BEFORE the examination of your pet.

We require full payment at the time that services are rendered. A deposit may be required at the time of drop off for hospitalization/surgical procedures and full payment at the time of pick up.

For your convenience, we accept cash, Visa, MasterCard, Discover, American Express, and Care Credit.

The undersigned is the owner and/or responsible person for the animal being cared for and authorizes the attending veterinarian to perform medical, dental, or surgical treatment as his/her professional judgment deems necessary. The undersigned understands that there may not be supervision of the animal when the clinic is closed.

The undersigned also accepts financial responsibility for the services rendered on behalf of the patient and understands that payment is due in full upon release of the patient from the hospital.

By initialing, providing your information and submitting this form you have read and consent to all of Adobe Pet Hospital's policies.

Initials *

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