New Client Registration Form

Hurley Vet Welcome Form

Thank you for giving us the opportunity to care for your pet(s). We will be happy to answer any questions you may have regarding your pets health. To ensure the best care possible, please complete this form. Thank you and welcome to the Hurley Vet family.
Today's Date

MonthDayYear
Date
Full Name

First NameLast Name
Is there a partner/spouse or any other name you would also like on your account?

First NameLast Name
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from above).

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please list the name and phone number of any additional parties that are authorized to use your account.
E-mail
example@example.com
Name and phone number of Employer/Business
Name and Phone Number of Emergency Contact
I authorize the above parties to use my account. I fully understand that if I wish to change/remove parties from my account that it is my responsibility to notify HVH in writing as soon as possible, and that I am responsible for all charges on my account by authorized parties up to and including all charges prior to receipt of written notification.

Signature of Primary Account Holder
How did you hear about us?
Please let us know who referred you so we can thank them!
Name and Phone Number of Your Previous Vet
Pet Registration

Please list your pets information below. If you have more than one pet that will be new to HVH please fill this section out for each of your pets.
#1-What is your pet's name?
Species
Breed
Color
Date of Birth

MonthDayYear
Date
Sex
Is your cat indoor, outdoor, or both?
Is your cat declawed?
Is your pet eating/drinking/urinating/defecating normally?
Please elaborate:
Is your pet experiencing any coughing/sneezing/vomiting/diarrhea?
Please elaborate:
What kind of diet do you feed your pet? What brand specifically?
Is your pet on any medications or supplements?
Please write the name of the medication, the dosage and how frequently you are giving these medications.
Is your pet on flea/tick medication?
What is the name of the flea/tick medication and do you give this year round?
Is your pet on heartworm prevention?
What is the name of the heartworm prevention and do you give this year round?
Does our staff need to be aware of any medical history/behavior before your appointment?
Does your pet (or anyone in your home) have any food allergies we need to be aware of? We often use peanut butter, cheese, tuna or other tasty snacks to help keep your pet calm and happy during their appointment. Please let us know if you would prefer we do not give them any snacks.
We like to make your pets visit as comfortable as possible so please let us know if there are things they enjoy or situations that make them uncomfortable, so we can provide the least stressful environment for them. (Ex: Lola loves crunchy treats and doesn’t like going on the scale).
Please attach any medical records you have for your pet or please have your previous veterinarian fax or email them to us at (845)331-1456 or info@hurleyvethospital.com.

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Do you have another pet we should add to your record at HVH today? You can also do this at the time of their appointment if they are not seeing the vet on the same day.
#2-What is your pet's name?
Species
Breed
Color
Date of Birth

MonthDayYear
Date
Sex
Is your cat indoor, outdoor, or both?
Is your cat declawed?
Is your pet eating/drinking/urinating/defecating normally?
Please elaborate:
Is your pet experiencing any coughing/sneezing/vomiting/diarrhea?
Please elaborate:
What kind of diet do you feed your pet? What brand specifically?
Is your pet on any medications or supplements?
Please write the name of the medication, the dosage and how frequently you are giving these medications.
Is your pet on flea/tick medication?
What is the name of the flea/tick medication and do you give this year round?
Is your pet on heartworm prevention?
What is the name of the heartworm prevention and do you give this year round?
Does our staff need to be aware of any medical history/behavior before your appointment?
Does your pet (or anyone in your home) have any food allergies we need to be aware of? We often use peanut butter, cheese, tuna or other tasty snacks to help keep your pet calm and happy during their appointment. Please let us know if you would prefer we do not give them any snacks.
We like to make your pets visit as comfortable as possible so please let us know if there are things they enjoy or situations that make them uncomfortable, so we can provide the least stressful environment for them. (Ex: Lola loves crunchy treats and doesn’t like going on the scale).
Please attach any medical records you have for your pet.

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I hereby authorize the veterinarian to examine, prescribe for, or treat the above pet(s). I assume full responsibility for all charges incurred for the care of these pets. I fully understand that payment is expected at the time of services rendered and that all charges will be paid in full at the time of visit or at discharge. A deposit will be required for all emergency treatment.

Signature of Owner/Authorized Agent:
HVH maintains an online presence through the posting of videos and pictures of patients and sometimes clients. Please indicate if you would allow, or prefer not to have your pet photographed for social media.
Should be Empty:

Hurley Vet Welcome Form

Pet Registration