New Client Registration Form

PERKINS ROAD VETERINARY HOSPITAL

Name*

Cell Phone*

Area CodePhone Number

Address*

City*

State

Zip Code*

Spouse

Spouse's Cell

Employer

Work Phone

Area CodePhone Number

Email*

example@example.com

Driver's license

State laws require that we obtain this information in the event that the doctor prescribes you pet any controlled/monitored medications.

Pet's Name*

Pet's Birthday*

Estimated date of birth is fine

Species: Canine/Feline*

Breed

Color

Gender/Sex of Pet

Fixed/Intact

has your pet been spayed/neutered?

Date of last Vaccines

If applicable

Prior Veterinarian

If applicable

Please list any known allergies to drugs or vaccines.

Known Allergies/Reactions to Medication

List any medications your pet takes regularly(Heartworm Flea prevention etc.)

Pet's Microchip #

If applicable

> I am the owner of the animal named above, and I agree to hold Perkins Road Veterinary Hospital and its personnel harmless for any disease contracted by said animal during its stay that could have been prevented by a proper preventative medication program. I realize that vaccinations given upon admission to the hospital will not have enough time to fully protect that animal on the particular visit.

>I realize that pets are only discharged during regular office hours and that any pet left in excess of ten days of the stated discharge date will be considered abandoned.

>I also realize that FULL payment is due UPON RELEASE OR END OF SERVICE. Applications to defer payment MUST BE made in ADVANCE and all unpaid balances will be subject to a finance charge of 1.5% per month. (18% year), with a minimum monthly processing fee of $3 per

*In the event of a medical emergency I authorize the doctors and staff to perform any neccessary services or procedures that my be in the best intrest of my pet and understand that I am finacially responsible for any charges incurred.*

How did you hear about us?

Signed*

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