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New Client Registration Form
robert-admin
2017-05-20T07:07:36+00:00
New Patient/Client Information
WELCOME TO DRIPPING SPRINGS ANIMAL HOSPITAL
Thank you for giving us the opportunity to provide quality care for your pet(s).
Date
*
Owner's Name
*
Spouse/Other
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Home Phone
*
Work Phone
*
Cell Phone
*
Email Address
*
Employer's Name & Address
In case of EMERGENCY, please call
*
at phone number
*
How did you first hear of our hospital?
Brochure
Hospital Sign
Facebook
Google
Yelp
Individual
Other
If Individual; someone we may thank?
Photo and Sharing Authorization: We love treating your pets and enjoy the time you allow us to spend with them. On occasion, we would like to capture these moments in photo/video. These photos may be emailed to you as an update on their status/progress, used on our website, or shared on social media sites such as Facebook. Do you authorize us to photograph/video your pet for these purposes?
*
Yes
No
PAYMENT IS DUE IN FULL AT THE TIME SERVICES ARE RENDERED
I understand that if I do not pay this account as agreed, the account is subject to costs of collection, attorney fees, and including interest (any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum). Return check fee is $30.00 plus tax. I understand that the hospital staff will provide an estimate of current and anticipated charges any time I request one. I am requesting that veterinary care be provided for pets presented by me or my agents. I understand that I am financially responsible for all services provided.
To prevent the spread of infectious disease and parasites all in-patients, out-patients, boarders and grooming pets must be current on all vaccines and be free of parasites. I understand this to be the strict policy of the clinic and authorize the doctors to provide my pet or pets with vaccinations and parasite control as needed.
Signature
*
Date
*
About Pet 1
Name
*
Species (cat, dog, other)
*
Breed
*
Description (color)
*
Age
*
Date of Birth
*
Sex
*
Neutered or Spayed
*
Diet (kind of pet food)
*
Hours Spent Outside Each Day
*
Microchip Number
Temperament: Has your pet ever bitten anyone?
*
Any other temperament concerns? Please explain.
VACCINATION & LAB HISTORY
(Dates Last Given)
(Dog) DHLPPC
(Dog) Bordetella
(Dog) Rabies
(Dog) Heartworm Test
(Dog & Cat) Heartworm Prevention
(Dog & Cat) Stool Check
(Cat) FVRCP
(Cat) Leukemia
(Cat) Rabies
(Cat) Feline Leukemia Test
(Cat) Feline Aids Test
Name and phone # of previous Veterinarian or Hospital for vaccination/medical history on your pet(s):
About Pet 2
Name
Species (cat, dog, other)
Breed
Description (color)
Age
Date of Birth
Sex
Neutered or Spayed
Diet (kind of pet food)
Hours Spent Outside Each Day
Microchip Number
Temperament: Has your pet ever bitten anyone?
Any other temperament concerns? Please explain.
VACCINATION & LAB HISTORY
Dates Last Given
(Dog) DHLPPC
(Dog) Bordetella
(Dog) Rabies
(Dog & Cat) Heartworm Test
(Dog & Cat) Heartworm Prevention
(Dog & Cat) Stool Check
(Cat) FVRCP
(Cat) Leukemia
(Cat) Rabies
(Cat) Feline Leukemia Test
(Cat) Feline Aids Test
Name and phone # of previous veterinarian or hospital for vaccination/medical history on your pet(s):
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