Client Information

Name *

First

Last

Spouse/Other Party Name

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Daytime Phone

Phone Type

Phone Number *

Evening Phone

Phone Type

Phone Number *

E-Mail Address *

Patient Information

Pet's Name

Age: Years, Months

Type of Pet *

If other, please explain: *

Breed *

Sex *

Male
Female

Neutered/Spayed *

Neutered Male
Spayed Female

Are your pet's vaccines current? *

Yes
No
Unsure

Do you have access to your pet's medical records? *

Yes
No

Are the medical records at another veterinary practice? *

Yes
No

Name of Former Veterinary Practice *

May we request a transfer of records? *

Yes
No

Would you like us to call you for your appointment? *

Yes
No

Reasons or conditions that prompted your visit? *

Special requests or conditions? *

Please list any additional pets here:

Our pet(s) is a

Family member
Child's pet
Backyard pet
Hunting/Working animal

How did you learn of our practice?

If referred by a previous client, whom may we thank? *

Please list any previous serious illnesses or surgery (explain):

Please list any known allergies to vaccines or medications:

Please list any medications or special diets your pet receives :

Please indicate your choice of payment type: *

Would you like to be present during treatment of your pet?

Yes
No

Terms and Policies

I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Carr Veterinary Hospital and that charges are due and payable at the time of service unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum.

Any balance that I leave unpaid will be forwarded to Carr Veterinary Hospital's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.

I hereby grant Carr Veterinary Hospital and its agents the right to use images of myself or my pet(s) in connection with its promotional materials in any and all media including printed material, the internet, and film. Any such use of images will be anonymous without any owner and patient name or identifying information. The copyright of any images collected are solely owned by Carr Veterinary Hospital.

I have read and understand the above policies. *

I Agree
I Disagree

Signature *

Clear Signature

Online Form

New Client Form

New Client Check-In

Client Information

Daytime Phone

Evening Phone

Patient Information

Terms and Policies

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