Arbor Hills Veterinary Clinic - New Client Registration Form

Owner's Name(Required)

First Last

Main Phone(Required)

Co-Owner's Name

First Last

Co-Owner's Phone

Cell Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

In Case of EMERGENCY, please call:

Name

Phone

May we text or email you as needed?(Required)

Yes

Which do you prefer?(Required)

Preferred phone number for us to contact you?(Required)

Home

Cell

Work

Spouse/Other

How Did You Hear About Us?(Required)

May we leave results at your primary phone or email(Required)

Yes

Which do you prefer?(Required)

Employer’s Name

Work Phone

Employer Address

Street Address Address Line 2 City State ZIP Code

May we use pet’s photo in social media?(Required)

Yes

By choosing YES you are authorizing Arbor Hills Veterinary Clinic to publish information/photos/videos from my pet(s) visit through their social media platforms. No signalments or names may be used to protect my identity. I understand that in no form will I (the owner) or my pet(s) be slandered. This is for education purposes only.

Please list all pets we should have/keep on file(Required)

Previous Veterinary hospital/clinic

Please attach the pet's we are seeing previous records

Drop files here or

Max. file size: 16 MB.

24 HOURS NOTICE REQUIRED FOR CANCELLATION, FAILURE TO DO SO WILL RESULT IN A NO CALL/NO SHOW. TWO NO CALL/NO SHOWS ACCUMULATED IN A 60-DAY PERIOD WILL RESULT IN BEING REQUIRED TO PRE-PAY ALL EXAM FEES BEFORE SCHEDULING ANY APPOINTMENTS. THREE NO SHOWS OR RESCHEDULES ACCUMULATED IN A 90-DAY PERIOD WILL RESULT IN DISMISSAL FROM OUR PRACTICE.

AUTHORIZATION: I HEREBY AUTHORIZE THE VETERINARIAN TO EXAMINE, PRESCRIBE FOR, OR TREAT THE PET(S) LISTED ABOVE. I ASSUME RESPONSIBILITY FOR ALL CHARGES INCURRED IN THE CARE OF THIS ANIMAL. I UNDERSTAND THAT THESE CHARGES MUST BE PAID AT THE TIME OF RELEASE AND A DEPOSIT MAY BE REQUIRED FOR TREATMENT.

Owner Signature(Required)

Print Name(Required)

Date(Required)

CAPTCHA