Specialty Registration

Specialty - New Client Registration Form
6700 Laurel Bowie Road, Bowie, MD 20715

(P) 301-809-8800 (F) 301-809-0900
OWNER (PRIMARY CONTACT) INFORMATION
Have you been to our facility before*

YesNo
First*
Last*
E Mail*
example@example.com
Street Address*
Apt*
City*
State*
Zip*
Cell Phone*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Please check your primary phone number

Cell PhoneHome PhoneWork Phone
Secondary Contact Name
Secondary Phone
Relation
PET INFORMATION
Pet Name*
Breed*
Species*

DogCat
Sex*

FemaleMale
Is your pet neutered / spayed*

YesNo
Color*
Date of Birthdate

MonthDayYear
Date
Yearsblanks Months blank
Does your pet have allergies to medications?*
PRIMARY VETERINARIAN INFORMATION
Name of Veterinarian
Name of Clinic (If Banfield, specify which location)
If you were referred by a veterinarian other than your Primary, please list name / clinic below
PET INSURANCE
Does your pet have insurance*

YesNo
If yes, what type of insurance

TrupanionFetchEmbrace
If other, please specify insurance
Policy Number (if known)
TRANSLATION SERVICES
Would translation services be helpful to you?

YesNo
If "Yes" What language will we need to translate?
DISCOUNTS
Do you qualify for one of the discounts listed below

Rescue OrganizationFirst ResponderMilitary & VeteransVet & Vet SupportI do not qualify
If you qualify for one of the discounts listed above, please provide one of the following documents to verify: DOCUMENTATION OF 501C3, / FIREFIGHTERS ID / EMTS ID /PARAMEDICS ID / LAW ENFORCEMENT ID / MILITARY ID / DD214 / VA ID / MD VET LICENSE, VETERINARIAN ID OR NAME BADGE / VET TECH ID OR NAME BADGE
LEGAL
You will be advised of the recommended diagnostic procedures and associated costs before proceeding with a treatment plan for your pet. Payment is required at the same time your pet is discharged from the hospital. If your pet requires hospitalization, a minimum pre-payment of 100% of the high end estimated charges is required. By signing below, I authorize Dogs & Cats Emergency & Specialty to charge my credit card or other payment method on file for any remaining balance due, if no other form of paymentis provided.

I understand that any balance remaining after discharge of my pet, if not collected within 30 days, may be placed in collections with a third party. I accept responsibility for payment of any fees associated with collections, including the reasonable attorney's fees and

I am the owner of the above described pet, or, am acting as an agent and have authorization from the owner to consent to the pet's treatment. I am at least 18 years of age. PHOTO ID REQUIRED- PLEASE ATTACH BEFORE FORM SUBMISSION I accept full financial responsibility for the services provided.
I give DCES permission to administer CPR to the above referenced pet if necessary:*

YesNo
Print Name*
Signature*

Clear
Date*

MonthDayYear
Date
Please upload a copy of your state ID or driver's license for verification purposes.*

Cancelof
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Specialty - New Client Registration Form

OWNER (PRIMARY CONTACT) INFORMATION

PET INFORMATION

PRIMARY VETERINARIAN INFORMATION

PET INSURANCE

TRANSLATION SERVICES

DISCOUNTS

LEGAL