New Client Registration Form

New Client Registration
What date do you have your appointment scheduled with us?*
Name*

First NameLast Name
Email*
example@example.com
YOUR Date of Birth (necessary for some prescriptions) *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Please enter a valid phone number.
Mobile Phone Number*
Please enter a valid phone number.
Add Secondary Contact
Secondary Contact Name

First NameLast Name
Secondary Phone Number
Please enter a valid phone number.
Do you have a pet sitter, neighbor, relative or friend who is authorized to bring in pet(s) and make treatment decisions in your absence
Name & Phone Number
Who can we thank for referring you?*

Drive ByGoogleYelpFacebookInstagramPersonal Referral (See Below)
Personal Referral, who can we thank?
*The highest compliment you can give us is to refer your friends to us! We will place a $25 credit on your account to spend any way you like at your next visit with us as a THANK YOU for the referral. Please ask for more details.
Can we feature your pet's photo and/or story on our social media accounts?

YesNo
If yes, what is your name/handle so we can tag you?

Pet's Name:*
Date of Birth:*
Breed:*
Color:*
Sex:*

Male IntactFemale IntactMale NeuteredFemale Spayed
Name of hospital/facility with previous medical records:
ADD Another Pet
Pet's Name:*
Date of Birth:*
Breed:*
Color:*
Sex:*

Male IntactFemale IntactMale NeuteredFemale Spayed
Name of hospital/facility with previous medical records:
Please upload any previous medical records that you have for your pet(s)

Cancelof
Do you have Pet Insurance?

YesNo
If yes, what is the name of the Pet Insurance Company
File Upload

Cancelof
Please upload a photo of your pet (recommended but not required)
Declaration: If my account should become delinquent, I am responsible for valid collection costs & attorney fees. A finance charge of 1.5% per month (or a $8.00) charge, whichever is greater is due on all balances owed over 30 days.
Signature:*

Clear
Please verify that you are human*
Should be Empty: