New Client RegistrationPrimary Contact Name(Required) First Last Primary Contact Phone Number(Required)Primary Contact Email Address(Required) Secondary Contact Name & Number(Required) Home Street Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Pet InformationPet's name #1(Required)Species(Required) Dog CatGender(Required) Male – Intact Male – Neutered Female – Intact Female – Spayed UnknownAge / DOB(Required)Breed(Required)Color(Required)Any Other Pets? Yes NoPet Information #2Pet's name #2(Required)Species(Required) Dog CatGender(Required) Male – Intact Male – Neutered Female – Intact Female – Spayed UnknownAge / DOB(Required)Breed(Required)Color(Required)This field is hidden when viewing the formSection BreakHow did you hear about us? Family/Friend Internet search Facebook/Instagram/Social Media Drove By Other / not listedDo you currently have Pet Insurance?(Required) No Yes , I have insurance for my pet No & would like to learn morePhotograph and Video Release: There may be times we would like to share a photo or video of your pet with our social media sites (Ex/ website, Facebook, Instagram, etc.) Please indicate your wishes below:(Required) Yes, you may use my pet’s photo No thank youNotification Settings – We use text messages and email to communicate appointment reminders, as well as your pet's health reminders (vaccines, exams, etc), and occasional clinic notices. If you would like to opt OUT of these reminders, please indicate below.(Required) EMAIL & TEXT both OK EMAIL OPT OUT – you may not receive notifications when your pet is due for vaccines/ exams TEXT OPT OUT – you may not receive messages about appointments OPT OUT of BOTH Email & TextI, the undersigned, am the owner or agent for the owner of the animal(s) described, and I have the full and exclusive authority to execute this consent.I certify that I am 18 years of age or older.I give permission to doctors, staff, authorized agents, or representatives of this hospital to examine, prescribe for, and treat my pets.I agree to pay for all services rendered and medications, goods, and supplies when purchased.I understand that all fees are due at the time services are rendered and the hospital accepts cash, check, and all major credit cards.Pet Insurance is encouraged. Visit Pawlicy Advisor for more information.If desired, financing options are available through SunBit, CareCredit and Scratchpay.I understand that a deposit may be required for surgical or medical treatment.Irelease this hospital from any and all liabilities.By my signature below, I hereby acknowledge that I agree to all of the above and acknowledge the receipt of a copy of this agreement upon request.Owner/Agent Name(Required)Date(Required) MM slash DD slash YYYY Owner/Agent Signature(Required)Is there anything else you'd like us to know?Δ
