Pioneer Veterinary Hospital Customer Registration Form

Pioneer Veterinary Hospital Customer Registration Form
Thank you for choosing our animal clinic. We pride ourselves in offering high quality medical care and emphasize preventative medicine. We look forward to serving you and caring for your pet's needs. Please complete this form so we can accurately enter this information into our files. To open an account with us, you must be at least 18 years of age.
Name

First NameLast Name
Co-owner Name:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Secondary Phone:

Area CodePhone Number
Employer:

First NameLast Name
Work Phone:

Area CodePhone Number
Co-owner Employer:

First NameLast Name
Work Phone:

Area CodePhone Number
Emergency Contact:

First NameLast Name
Phone Number

Area CodePhone Number
Preferred method of communication: (Check one)

Post MailPhoneText
Email
example@example.com
*The following information is required for your account and is strictly CONFIDENTIAL:
SSN -or- Drivers License No.
State and- Birthdate
IMPORTANT FINANCIAL INFORMATION

Payment is expected when services are rendered. We accept cash, checks, and Visa/MasterCard and Discover. We also offer Care Credit.

I hereby authorize the doctor and technicians to administer services/treatment as explained to me by the doctor. I assume all financial responsibility for all charges incurred for the care and treatment of my pet(s). I understand that services are to be paid for when rendered.

At my request, I will receive a written estimate for services for anything other than routine care which I may decline for any reason.
Owner Signature

Clear
Date

MonthDayYear
Date
Should be Empty: