Companions Animal Hospital

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 & Email (required)
First Name (required)
Last Name (required)
Spouse or Partner
First Name
Last Name
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
Work Phone
Phone TypePhone Number
May we contact you at work?

Fax #
Phone TypePhone Number
Drivers License #

E-Mail Address :
Place of Employment

Spouse/Partner Place of Emloyment

Spouse/Partner Work Phone
Phone TypePhone Number
May we conact your spouse/partner at work?

So that we may thank someone, how did you hear about us?

To keep costs lower, PAYMENT IS DUE THE SAME DAY SERVICES ARE PERFORMED. I will pay by:
a Cash
b Check with proper identification
c Visa
d Mastercard
e Discover
f Care Credit

I have Veterinary Pet Insurance and need forms signed
Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed:

Sex: (required)
Male
Female

Neutered/Spayed
Neutered
Spayed

Pet's color/markings

Are your pets vaccines current?
Do you have pets medical records?
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
In case of an emergency where you can not be immediately contaced, you want us to
a Provide CPR to your pet(s)
b Do not resusitate your pet(s)

What method of contact do you prefer for non-emergency matters regarding your pet
a phone
b mail
c email

Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

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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