New Patient Registration | American Veterinary Hospital

Name*

First

Last

Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Owner's Date of Birth*

Owner’s Drivers License Number / State of Issuer*

Day-Time Phone*

Evening Phone

Mobile Phone

Email*

Enter Email

Confirm Email

Co-owner's Name & Contact #

Name

First

Last

Phone

How did you find out about our practice?

Clinic Location
Personal Referral
Internet Search / Website
Yellow Pages
Clinic Sign
Newspaper / Print Media
Other

What Social Media Platforms do you use?

Facebook
Instagram
Twitter
Snap Chat
Pinterest
I do not use any

If Other, please specify:

If Personal Referral, is there someone we can thank for this referral?

Please use this area to give us any other relevant information about yourself or your family

Pet Information

Pet's Name*

Pet's Name at time of Adoption

(if adopted from Woof Gang Rescue)

Species*

or if other species

Breed*

Color*

Date of Birth or Age*

Special Identification (tattoo, microchip, etc.)*

Sex*

Previous Veterinary Practice / Previous Veterinarian (if any)*

Do we have your permission to collect records?

Yes
No

Date of last vaccines (if known)

What vaccines were given at this time

Is your pet on any medication or supplement?*

Yes
No

If Yes, please list the medication or supplement

What food does your pet eat?

Does your pet have allergies or drug reactions?*

Yes
No

If Yes, please list the allergies and reactions

Are there any current or past medical conditions of which we should be aware?*

Yes
No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Please use the following box to give us any other relevant information about your pet

Do you have a second pet you would like to register with our veterinary hospital today?*

Yes
No

Photo Consent

We love social media! Do we have your permission to share your pet(s)’ image/video/story on social media, our website & other forms of related media? Your name and personal information will never be shared.

Simply Check If you Authorize the sharing of your pets!

Yes, I do authorize
No, I do not authorize

Pet Health Savings Plan

Say Goodbye to full price! Not only will you save 20% every invoice with our in-house savings plan but you also get bonus Pet Perk Points and a FREE Rabies vaccine!

Tell me more! I’d like more information on your Pet Health Savings Plan.
I am not interested in learning more about the plan at this time.

Treatment Consent

Upon signing this agreement, I certify I am the Owner/Authorized Agent of above pet(s) and have authorization to consent to treatment if and when needed. I authorize AVH to examine, prescribe for and/or treat the above pets. I recognize that financial concerns should be discussed PRIOR to exam & treatment. I understand I am entitled to ask for and be provided with a written estimate of fees regarding services and/or products prior to services being performed. I assume full responsibility for all charges incurred and understand these incurred charges are to be paid, IN FULL, at the time the services are rendered. (Accepted payment methods: Cash, Credit Card (Visa, Mastercard, Discover, American Express), Check (DL # required) and Care Credit.)

Signature*

Date*

CAPTCHA

New Patient Registration Form

Co-owner's Name & Contact #

Pet Information

Photo Consent

Pet Health Savings Plan

Treatment Consent

Get in touch

414-304-1818

Business Hours