SBPH New Client Form

1
Have you ever brought a pet to St. Boni Pet Hospital before?* This field is required.
Yes
No
2
Owner's Name* This field is required.
First Name
Last Name
3
E-mail* This field is required.We provide our clients with online access to their pet(s) records and the ability to receive medical and appointment reminders, news and other updates by email.
4
Main Contact Number:* This field is required.
Area Code
Phone Number
5
Secondary Contact Number:
Area Code
Phone Number
6
Address:* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
How Would You Prefer To Be Contacted?* This field is required.
Phone (Main Number)
Phone (Secondary Number)
Text (Main Number)
Text (Secondary Number)
Email
8
Is There a Spouse/Partner/Family Member Who Should Be Listed On Your Account?
Yes
No
9
Spouse/Partner/Family Member Name
First Name
Last Name
10
Please tell us how the above person is related to you so we can refer to your relationship appropriately.
11
Spouse/Partner/ Family Member Contact Number:
Area Code
Phone Number
12
13
In case of emergency...
14
Is there anyone else (besides above listed contacts) who should be listed on your account, who has ongoing permission to make medical decisions for your pet(s)?
Yes
No
15
Emergency Contact:
First Name
Last Name
16
Relationship
17
Contact Number
Area Code
Phone Number
18
Additional Account Name
First Name
Last Name
19
Relationship
20
Contact Number
Area Code
Phone Number
21
22
How did you hear about us?* This field is required.
Sign/Our Location
Welcome Neighbor
Humane Society
Google (or other search engine)
Facebook
Instagram
NextDoor.com
www.stbonipethospital.com
Is there someone we can personally thank for your referral?
23
Please tell us who we may thank for your referral!
24
Pet's Name* This field is required.
25
Upload A Picture of Your Pet
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
26
Species* This field is required.
Dog
Cat
27
Date of Birth/Age of Your Pet* This field is required.
28
Breed & Color (If your cat is not a known breed, do they have long, medium or short hair?)* This field is required.
29
Sex* This field is required.
Male
Neutered Male
Female
Spayed Female
30
Is Your Pet Microchipped?* This field is required.
Yes
No
I'm not sure
31
Primary Reason for Visit to St. Boni Pet Hospital?* This field is required.
32
Do You Already Have a Scheduled Appointment?* This field is required.
Yes
No
I scheduled an appointment through your website/over the phone
33
Appointment Date
Date
Month
Day
Year
34
Appointment Time
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
PM
AM
PM
35
Previous Veterinarian(s)* This field is required.Name, Location and Contact Information of Prior Veterinary Hospital(s)
If None, Please Let Us Know That.
36
Previous Veterinarian(s)* This field is required.
If none, please let us know that!
37
Upload Previous Veterinary Records
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Please upload if available.
Cancelof
38
Do You Have More Than One Pet At Home?
Yes
No
39
Pet #2 Name* This field is required.
40
Upload A Picture of Your Pet
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
41
Species* This field is required.
Dog
Cat
42
Date of Birth/Age of Your Pet* This field is required.
43
Breed & Color (If your cat is not a known breed, do they have long, medium or short hair?)* This field is required.
44
Sex* This field is required.
Male
Neutered Male
Female
Spayed Female
45
Is Your Pet Microchipped?* This field is required.
Yes
No
I'm not sure
46
Do you have more than 2 pets at home?
Yes
No
47
Pet #3 Name* This field is required.
48
Upload A Picture of Your Pet
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
49
Species* This field is required.
Dog
Cat
50
Date of Birth/Age of Your Pet* This field is required.
51
Breed & Color (If your cat is not a known breed, do they have long, medium or short hair?)* This field is required.
52
Sex* This field is required.
Male
Neutered Male
Female
Spayed Female
53
Is Your Pet Microchipped?* This field is required.
Yes
No
I'm not sure
54
Pet #4 Name* This field is required.
55
Upload A Picture of Your Pet
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
56
Species* This field is required.
Dog
Cat
57
Date of Birth/Age of Your Pet* This field is required.
58
Breed & Color (If your cat is not a known breed, do they have long, medium or short hair?)* This field is required.
59
Sex* This field is required.
Male
Neutered Male
Female
Spayed Female
60
Is Your Pet Microchipped?* This field is required.
Yes
No
I'm not sure
61
This form supports telling us about 4 pets in your home. If you have more than 4 pets, please let our receptionists know and we will happily collect information to add them to your account.
62
We Love Social Media! Do we have your permission to post pictures of your pet(s), you & your pet(s), and/or your pet(s) with our team on Facebook, Instagram, www.stbonipethospital.com, and any other marketing and/or other social media outlets we may choose to use?* This field is required.
Yes
No
63
Do you authorize St. Boni Pet Hospital to release medical information on your pet(s) to another veterinary clinic, local law enforcement (e.g.: in the case of rabies vaccination verification), or boarding facilities/groomers requesting vaccination and laboratory history?* This field is required.If you select No (meaning you prefer to personally contact us) to release medical information on your pet, please keep in mind that we will have to contact you for consent before giving out any information. This may be time-sensitive in the cases of you dropping your pet off at grooming facilities, boarding, etc. that may not have your pet's updated records.
Yes
No
64
St. Boni Pet Hospital uses email and text communications in addition to our phone call reminders regarding patient reminders for health care needs. Do we have your permission to contact you via email and text regarding these reminders?* This field is required.
Yes
No
65
FINANCIAL POLICY:

Our clinic accepts Visa, Mastercard, Discover, and American Express. We also accept cash.
*We do not accept checks.

In addition, we also offer several 3rd party financing options for our clients via Care Credit and Scratchpay. We accept a variety of Care Credit plans based on the total transaction amount for your pet. Care Credit requires that payment only be made for services as they are rendered, we cannot charge services to your account in advance. Therefore, Care Credit cannot be used for PAW plan services. Additionally, use of Care Credit requires that the card be present every time and that two forms of identification may need to be verified. We appreciate your understanding of our desire to protect your account/identity.

As financing options are offered, we cannot offer additional in-house payment plans for our services. Clients needing additional financial support are encouraged to apply for Care Credit with a co-signer.

Full payment is due at the time of service. Your signature below indicates your agreement with these policies.
66
TREATMENT CONSENT:

By signing this document, I declare I am the lawful owner of all listed pets and all information is true and correct to the best of my knowledge. I hereby authorize the veterinarian(s) of St. Boni Pet Hospital to examine, prescribe for or treat the my pet(s) to the best of their abilities. I assume responsibility for all charges incurred in the care of this animal. I acknowledge that medical information will not be released to anyone not indicated on this form without my express verbal and/or written permission with the except of another veterinary facility.
67
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