Pet Parent Registration Form

Pet Parent Name*

First NameLast Name

Pet Parent Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Secondary Contact Name

RelationshipFirst NameLast Name

Secondary Contact Phone Number

Please enter a valid phone number.

In order to dispense medications, we require your SSN or your drivers license number and date of birth. Which would you like to provide?*

Social Security NumberDrivers License and Date of Birth

Social Security Number NA if providing DL* Drivers License NA if providing SSN* and Date of Birth Date of Birth*

Please verify you understand our cancellation policy*

I understand and agree

Signature*

Digital Signature

What pet are you bringing in? *

Pet Name

What type of animal are they?*

What is their estimated age? *

What color are they? Do they have any special markings?*

What is their gender?*

Who is your primary vet? *

N/A if none

Payment is due at time of service. Acceptable forms of payment are cash, Visa, Mastercard, Discover, Care Credit and Scratch Pay*

I understand

We are not able to offer payment plans at this time, but we do accept third-party payment options with Care Credit and Scratch Pay. This would allow you to start treatment today, and spread payments over time. Applying for either only takes minutes and there is no fee to apply.*

I understand

All prescription drugs are regulated by the FDA and must be approved for specific use in humans and/or specific animals at specific doses. To be approved, each drug must go through a series of testing and analysis to understand not only the benefits and effects, but also the side-effects and risks of its use typically in dogs and cats and, in some medications, horses, cows, pigs and occasionally chickens, rats and rabbits. At this time, no drug or pharmaceutical is approved by the FDA for use in any pet bird, reptile or most small exotic mammals, and very few are approved in rats and rabbits. Use of pharmaceuticals in species for which they are not approved is allowed, however, and is termed “Extra-Label Use.”*

I understand

The undersigned acknowledges that Extra-Label Use of pharmaceuticals is acceptable therapy to be used in their pet or animal, as deemed necessary by the attending veterinarian and they have read and understand both our Billing and Pharmaceutical Use policies.*