New Client Registration Form - Sunset Hill Veterinary and Rehabilitation Center

Name(Required)

First Last

Phone(Required)

Name

First Last

Phone

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

During regular office hours how would you generally prefer we contact you:

First Phone Number

Second Phone Number

How did you hear of our clinic?

Sign/Walking By

Referral

Recommendation

Advertising

If recommended / referred, please tell us by whom?

Pet Health History

Name of pet(Required)

Species

Dog

Cat

Breed(Required)

Color(Required)

Age or DOB(Required)

Sex

Male

Male-Neutered

Female

Female-Spayed

Patient Records

Would you like to request a copy or your pet(s) previous records?

Yes, I would like you to request a copy of my pet(s) previous records.

No, I will call my previous vet to have them fax a copy of my pet(s) records to you.

Reason for visit

Authorization:

I hereby authorize the veterinarian to examine, prescribe for, or treat the above-described pet.
I assume responsibility for all charges incurred in the care of this animal.
I also understand that professional fees are due at the time services are rendered and that a deposit may be required for surgical treatment.

We will gladly prepare a written estimate if you desire. Please ask any staff member.

Signature

Date

Video-Photo Release

I grant Sunset Hill Veterinary & Rehabilitation Center, its representatives and employees the permission to take pictures and/or video of me and/or my pet(s), and to use, copyright, and/or publish the same in print and/or electronically.

I agree that Sunset Hill Veterinary & Rehabilitation Center may use such pictures and/or video of me and/or my pet(s) with or without the name(s) of my pet(s) and/or my name and for any lawful purpose, including, for example, such purposes as educational, publicity, advertising, and Web content.

May the above take photos of you and/or your pet(s)

The above may take photos of me and/or my pet(s)

The above may NOT take photos of me and/or my pet(s)

Pet Name(Required)

Signature

Date

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