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
* Owner's Name 1:	Owner's Name 2:
* Address:	* City:
* State:	* Zip:
Phone (H):	Phone (C):
Employer:	Work #:
Patient Information
Name:	ID #:
Type: Choose Cat Dog Other	Sex: Choose Male Female Choose Spayed Neutered Intact
Breed:	Color:
Birth date:
Referring Veterinarian
Name:	Hospital:
Phone:	Fax:
Primary reason for visit:
Did you bring x-rays with you? Choose Yes No
Accepted forms of payment: Cash, Visa, MasterCard, American Express, Discover, Care Credit and Citi Health. All Checks are electronically processed. Check writer must be present with their valid drivers license. If check cannot be electronically processed, we will require another form of payment. If paying by Credit card, Care Credit, or Citi Health, 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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