Affiliated Veterinary Specialists

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Print-friendly version

Download a print-friendly version of our new patient registration form in PDF format and bring it with you to your appointment.

Preparing for a Visit : New Patient Registration Form

Client Information
Client ID#:
* Owner's Name 1:	Owner's Name 2:
* Address:	* City:
* State:	* Zip:
Primary Phone #:	This is my... Choose Home Cell Work
Seconday Phone #:	This is my... Choose Home Cell Work
Additional Phone #:	Employer:
Email Address:
Patient Information
Name:	Patient ID #:
Type: Choose Cat Dog Other	Sex: Choose Male Female Choose Spayed Neutered Intact
Breed:	Color:
Birth date/Age:
Referring Veterinarian
Name of Referring Veterinarian:	Name of Hospital:
Phone:	Fax:
If you have a 2nd veterinarian that you would like us to keep informed, please complete the following:
Name of Referring Veterinarian:	Name of Hospital:
Phone:	Fax:
Did you bring x-rays with you? Choose Yes No	If you did, are they on a CD? Choose Yes No
Primary Reason for visit:
Accepted forms of payment: Cash, Visa, MasterCard, American Express, Discover, and Care Credit. All Checks are electronically processed. Check writer must be present with a driver's license. If check cannot be electronically processed, we will require another form of payment. If paying by Credit card, Care Credit or Citi Health, the cardholder must be present with their card and a valid I.D.
Authorization
I assume responsibility for all charges incurred in the care of this patient. I also understand that these charges are to be paid at the time of treatment and that a 75% deposit will be required for all procedures.

General Appointment Information · FAQs · New Patient Registration Form

 

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