muiroaksvet.com-CLIENT REGISTRATION

MUIR OAKS VETERINARY HOSPITAL
CLIENT REGISTRATION

Thank you for taking the time to complete this form. The following information will help us meet our goals of communication effectively with you, and providing the best possible care for you pet(s).
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Owner’s Name

First NameLast Name
Spouse/Other
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Cell Phone
Social Security #
Current Email
example@example.com
Driver’s License
Client Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
(for controlled substances, prescriptions & senior discounts)
Employer Name

First NameLast Name
Employer Phone Number

Area CodePhone Number
At what time and at what number is it best to call about your pet(s)?
My preferred method of payment is : (please check one)
In case of EMERGENCY,
please call

First NameLast Name
at telephone number

Area CodePhone Number
Pet’s name
Approx. Date of Birth
Other
Sex
Breed
Color
(Continue on reverse for additional pets)
Previous/Current s)Previous/Current Veterinarian
Should we send for past veterinary records?
How did you first hear of us?

Other
Individual we may thank for personal referral:
I hereby authorize Muir Oaks Veterinary Hospital to examine, prescribe for and treat my pet(s). I understand that professional fees are to be paid at the time of service and that a deposit may be required in some circumstances. I also understand that I am responsible to pay for all charges incurred in the care of my pet(s), including reasonable attorney’s fees and cost of collection in the event of default. I further understand that if payment becomes 30 days past due, delinquency charges at the maximum allowable rate, will be due on delinquent amounts from the date the payment was due.
Owner or Responsible Party
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Signature
Should be Empty: