Preparing for a Visit : New Patient Registration Form

Owner's Name 1:

Owner's Name 2:

Address:

City:

State:

Zip:

Phone (H):

Phone (C):

Employer:

Work #:

Name:

ID #:

Type:

Choose Cat Dog Other

Sex:

Choose Male Female
Choose Spayed Neutered

Breed:

Color:

Birth date:

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 and Care Credit. All Checks are electronically processed. Check writer must be present and a copy of driver's license will be kept on file. If check cannot be electronically processed, we will require another form of payment.

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.