New Client Registration Form

Dogwood Acres Veterinary Clinic

New Client Registration Form

Client # ______

LAST NAME ______FIRST NAME______SPOUSE/PARTNER ______

ADDRESS ______

CITY ______STATE ______ZIP CODE ______

HOME PHONE ______CELL PHONE ______

SPOUSE/PARTNER CELL PHONE______

************WE DO NOT ACCEPT CHECKS AS PAYMENT FOR SERVICES*****************

PREFERRED METHOD OF PAYMENT: □CASH □MASTERCARD □VISA □CARE CREDIT

EMAIL ______

EMERGENCY CONTACT ______PHONE NUMBER ______

PLACE OF EMPLOYMENT______WORK #______

PATIENT INFORMATION:

HOUSEHOLD PETS: Pet’s Name / Color / Species / Breed / Age / Sex / Altered? Y/N

MEDICAL HISTORY (Please Enter Date):

SPECIES / RABIES / DA2/FVRCP / BORDETELLA / MICROCHIP / HEARTWORM TEST
CAT
DOG

Dogwood Acres Veterinary Clinic would like you to be aware that all fees are due at the time services are rendered. IF you pet is hospitalized, 50% prepayment of the estimate amount is due upon hospitalization before any treatment is performed the patient. We accept CASH, Visa, MasterCard, and Care Credit. We must also state that if your account becomes delinquent, it may be necessary to send that account to a collection agency and you will be responsible for any collection fees, legal and/or court costs.

Dogwood Acres Veterinary Clinic may take photographs of your pet for identification purposes or for medical progress reports, which shall become part of the medical record. By signing this form you authorize the use of photographs for these purposes.

By signing this form you acknowledge that you are the owner of the pet stated above and you have the right to authorize or deny any treatment for this pet. You understand that no guarantee can be made as to the outcome of veterinary treatment for your pet. By signing this you are stating that you are over 18 years of age and are financially responsible for all charges incurred for patients on your account.

Signature of Owner or Responsible Agent Date