New Client Registration

Primary Owner Name: *(The name the pet will be registered under at our clinic, the primary owner must be at least 18yrs old.)

Secondary Owner Name:(This person will have access to your pets’ records)

Relationship:

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Email Address *

Cell Number: *(This is where reminders and lab results will be sent)

Additional Number:

May we post pictures of your pet online, ex: Facebook, etc.?YesNo

Preferred Method of ContactPhone CallTextEmail

How were you referred?(Name if current client here for their $25 referral credit)

I understand that full payment is due at the time of service, and in some cases, a cash deposit will be required. (We accept Mastercard, Visa, American Express, Discover, Care Credit, Cash, Check, or Scratch Pay.)

Animal Hospital of Lanesville has my permission to inform other facilities of the health status of my pet. (Other veterinarians, boarding, grooming).

(Initial) Per Federal Law, I am aware that my pet MUST be current on RABIES VACCINE. If I cannot provide proof of a current rabies vaccine, one will be administered to my pet at my expense.

Digital Signature *

Date *

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