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Companions Animal Hospital

320-252-6700

"Complete Care from Head to Tail"

for dogs, cats, birds, reptiles and small mammals

New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

Form - New Client

Name (required)
First Name (required)
Last Name (required)
Spouse or Partner
First Name
Last Name
Children's Names/Ages

Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
E-Mail Address :
Home Phone (required)
Phone TypePhone Number (required)
Cell Phone
Phone TypePhone Number
Work Phone
Phone TypePhone Number
Place of Employment

May we contact you at work?

Best time/phone # to call regarding your pet's care:

Spouse/Partner Work Phone
Phone TypePhone Number
Spouse/Partner Place of Emloyment

May we conact your spouse/partner at work?

Emergency Contact
First Name
Last Name
Emergency Contact Phone #:

How did you first hear about us? (required)
Personal referral-friend/relative
yellow pages
civic group or community event
newspaper ad
radio ad
new resident program
direct mail or coupon
internet ad
pet store or humane society
sign,location,drove by
our website (www.companionsweb.com)
other

If you first heard of us from a personal referral, ad, event or other, please list who or which one

Why did you decide to come here? (required)
AAHA Accreditation! Ask us if you don't know about AAHA
Extended convenient hours (M-F 7am-6pm; Sat 9am-noon)
Sunday hours for pickup and admitting (pet accommodations only)
Overnight pet care M-F for hospitalized and healthy pets
Convenient Location
Pick Up and Delivery Options
We do housecalls
Referral/Reputation in the community
Lodging Facilities for dogs, cats (separate!), exotic pets
Person who answered the phone was friendly/competent
Laser Surgery available
Pain Management Services-Therapy laser, massage...
Veterinary Care for Exotics (birds,reptiles,rodents etc)

How do you view your pet(s) in terms of overall health concerns/issues?
As a family member (I am concerned about all health issues and recommendations)
As a pet (only concerned with basic health care such as exam and vaccinations)

Pet's Name (required)

Age: Years, Months

Type of Pet (required)
Canine
Feline
Avian
Exotic
Other

Breed: (required)

Sex: (required)
Male
Female

Neutered/Spayed
Neutered
Spayed

Pet's color/markings (required)

Date of pet's last examination

Please list all other pets below. Please include sex, if they are altered, breed and age.

Medical records at another veterinary Practice?
Yes
No

Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No

Would you like us to call you for your appointment
Reasons or conditions that prompted your visit?

Special requests or conditions?

May we use your pet(s) picture(s) on our website and other materials (bulletin boards etc)? (required)
Yes
No

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Companions Animal Hospital and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly service charge of 2% and a $5 handling fee. Any balance that I leave unpaid will be forwarded to Companions Animal Hospital's collection agency, and will incur a $35 collection fee for which I am liable, in addition to monthly finance charges.
I have read this statement and -
I Agree
I Disagree


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