New Patient Registration
Welcome! Thank you for giving us the opportunity to care for your pet. To ensure the best care possible, please take a moment to fill out completely. We also ask that you fill out our Patient Pre-exam history form found on our website.
Registration
Please select one
New Client to the Hospital
Current Client with New Pet
How did you hear about us?
Sign/Driveby/Walk-in
Website/On-line
Friend/Family
Please let us know who referred you so we can thank them!
Owner's Name
First Name
Last Name
Co-Owner
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
County
DeKalb
Kane
Kendall
LaSalle
Other
County
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Phone Type
Cell/Mobile
Home
Work
May we text this number?
Yes
No
Alt Phone Number
-
Area Code
Phone Number
Alt Phone Type
Cell/Mobile
Home
Work
May we text this number?
Yes
No
We sometimes feature our SVH family on our facebook page! Please check yes if you consent to sharing your pet's picture, we will always respect your privacy.
Yes, it is ok to share photos of my pet
No, my pet is camera shy!
Pet Health Information
Pet's Name
Date of Birth
/
Month
/
Day
Year
Date
Type of Animal
Dog
Cat
Other
Specify type of pet
Sex
Male
Female
Has your pet been spayed/neutered?
Yes
No
Unknown
Breed
Color
Previous Veterinary Hospital Name
Previous Veterinary Hospital Phone Number
-
Area Code
Phone Number
Any injury or illness in the past 30 days?
Yes
No
Please describe
Is your pet currently on any medications?
Yes
No
Please list below
Is your pet allergic to any drugs/medications/vaccines?
Yes
No
Please list below
Any food intolerance?
Yes
No
Please list below
Authorization
I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges in the care of the animal. I understand that these charges must be paid at the time of the release and that a deposit maybe required for surgical treatments.
Signature of Owner/Authorized Agent
Method of payment
Cash
Credit Card
Submit
Should be Empty: