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Home » Forms » New Client Registration Form

New Client Registration Form

"*" indicates required fields

Please complete the following form so we can get to know you and your pet(s) better!

New Client Information

Owner's First Name*

Owner's Last Name*

Primary Phone*

Email*

Co-Owner's First Name

Co-Owner's Last Name

Co-Owner's Phone

Co-Owner's Email

Address*

Street Address

Address Line 2

City

State

ZIP Code

Who can we call in the event of an emergency when you and your spouse/co-owner cannot be reached?*

Emergency Contact Name*

Emergency Contact Phone*

Relationship to You*

How did you hear about us?*

Yellow Pages

Radio

Building Sign / Drive By

Website / Internet Search

Newspaper

Humane Society

Another Veterinary Hospital

Personal Recommendation

Other

If a personal recommendation, who were you referred by?*

If other, please explain*

Pet Information

Pet's Name*

Species*

Cat

Dog

Breed*

If Known

Color*

Age*

If Known

Sex*

Female

Female Spayed

Male

Male Neutered

Microchip Number (if they have one)

Would you like to add a second pet?*

Yes

Pet 2 Information

Pet's Name*

Species*

Cat

Dog

Breed*

If Known

Color*

Age*

If Known

Sex*

Female

Female Spayed

Male

Male Neutered

Microchip Number (if they have one)

Do you want to add a third pet?*

Yes

Pet 3 Information

Pet's Name*

Species*

Cat

Dog

Breed*

If Known

Color*

Age*

If Known

Sex*

Female

Female Spayed

Male

Male Neutered

Microchip Number (if they have one)

Additional Information

What is the reason for your visit?*

May we obtain medical records from a previous veterinarian?*

Yes

Veterinarian / Clinic Name*

Phone*

Financial Responsibility

Do you have insurance for your pet?*

Yes

If yes, what pet insurance do you have?*

How do you anticipate paying for your pet's medical care?*

Cash

American Express

Visa

MasterCard

Discover

CareCredit

We pledge to provide our very best care for your pet’s health needs. In return we ask you to accept responsibility for charges incurred in the treatment of your pet and accept that payment is due when services are rendered. Please feel free to ask for an estimate and know we are happy to discuss fees prior to providing services.

We, at Companion Animal Care Center, love to feature client’s pets in our marketing. By signing below, I hereby give permission to use any and all photos of myself, my family, and my pets for internal, external, or internet marking purposes.

Consent

Please check this box if you would prefer NOT to have you or your pet’s picture used in our marketing.

I hereby authorize the veterinarian to exam, prescribe for, or treat my pet(s).

I assume responsibility for all charges incurred in the care of my pet(s). I also understand that these changes must be paid in full at the time of service.

Signature*