Great Oaks Veterinary Hospital - Owner and Patient Registration Form

Name

First NameLast Name

Email

example@example.com

Home phone

Enter phone numberFormat: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell phone

Enter phone numberFormat: (000) 000-0000.

Work phone

Enter phone numberFormat: (000) 000-0000.

Occupation

Employer

Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Spouse/Co-owner

First NameLast Name

Spouse/Co-owner employer

What is the best number to call you about your pet?

In case of emergency and we Cannot reach you, please call

Referred by

We will be happy to prepare a written estimate if you desire. Please ask the receptionist BEFORE services are rendered for an estimate if desired. PROFESSIONAL FEES ARE DUE AT THE TIME OF DISCHARGE. In some cases a deposit is required. A COPY OF YOUR DRIVER'S LICENSE IS NEEDED.

Pet's name

Birth Date/age

Breed

Species

Color

MF

YesNo

Date of last vaccines/labs

Which vaccines

Hospital which administered

YesNo

Pet's name

Birth Date/age

Breed

Species

Color

MF

YesNo

Date of last vaccines/labs

Which vaccines

Hospital which administered

YesNo

Pet's name

Birth Date/age

Breed

Species

Color

MF

YesNo

Date of last vaccines/labs

Which vaccines

Hospital which administered

I hereby authorize GREAT OAKS VETERINARY HOSPITAL, its representatives, agents, or employees, to examine, prescribe for, treat, or perform surgery and/or other services including the administration of such anesthetics as necessary, upon the above described animal(s).

Furthermore, I accept full financial responsibility for the payment of services rendered, including any reasonable legal costs and attorney's fees incurred in connection with collection for services. Balances over 30 days will incur a $3 billing charge and a 1.5% finance charge.

I understand any animal(s) not called for within three days after written or oral notification that the animal(s) is ready for release shall be disposed of at the discretion of the hospital. My financial responsibility shall to in any way be altered by such disposal and my indebtedness shall include all charges made against such animal(s) up to the at of disposal.

I also hereby release and forever discharge GREAT OAKS VETERINARY HOSPITAL, its owners, representatives, agents, or employees from any and all claims and demands whatsoever which I have or may have against GREAT OAKS VETERINARY HOSPITAL, its owners, representatives agents, or employees by reason of said surgery, administration of drugs or performance of other services, any consequences resulting directly or indirectly therefrom.

To prevent the spread of infectious diseases and parasites, hospitalized and boarded animals must be current on all vaccines and free of external and internal parasites. I authorize the doctor to provide vaccines and parasite control as needed for my pet(s).

All routine services (any services that are non emergency) must be paid at time of service.
A minimum deposit of 50% is required for all hospitalizations, to be paid at the time patients are admitted.
Emergency cases require half (50%) of estimated cost before we can begin extensive medical treatment.

I promise to inform the staff at Great Oaks Veterinary Hospital of any financial issues involving payment of services.

Signature

Use your mouse or finger to draw your signature above

Owner Information

Pet Information

Pet Information - Second Pet

Pet Information - Third Pet