New Client Registration

New Client Registration Form

"*" indicates required fields

Step 1 of 3

Client Registration

Why are you bringing your pet to Hope?

How did you become aware of our clinic?

Owner's Name*

First Last

Spouse’s Name (if applicable)

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code

Primary Phone*

Work Phone

Cell Phone 1

Cell Phone 2 (if applicable)

Preference for receiving reminders*

Text

E-mail

Preferred Email Address

Preferred Cell Phone Number

Email*

Place of Employment

Driver’s License Number*

Your Date of Birth*

Social Security Number

Name of nearest relative

First Last

Phone number of nearest relative

** We are a medical facility & require driver’s license for certain prescriptions.
** Please allow us to make a copy of your driver’s license.
** All client information is kept strictly confidential and is only released with your authorization.

Thank you for your cooperation

PLEASE LIST YOUR PETS:*

Name Cat/Dog/Other Age M/F

PLEASE LIST YOUR PETS:

Name Cat/Dog/Other Age M/F

PLEASE LIST YOUR PETS:

Name Cat/Dog/Other Age M/F

PLEASE LIST YOUR PETS:

Name Cat/Dog/Other Age M/F

Signature*

Financial Policy

Our Clinic does not receive support from charitable organizations nor does it receive government subsidies; therefore, prompt payment assures that this facility is well-stocked and well-equipped to provide your pet with quality medical care. Since prompt payment is necessary in order for us to be able to provide your pet with quality care, the following policies are mandatory. If you have any questions regarding the cost or extent of care needed by your pet, please feel free to ask.

1. All routine care and services must be paid for at the time of service

Example - Routine annuals or vaccinations, non-emergency visits, heartworm prevention, or flea control. We accept cash, personal checks, Visa, Mastercard, or Discover. We also accept Care Credit if you qualify. *Note: Clients paying with a personal check will be asked to verify their identity with a photo ID and supply a Social Security number.

2. AFTER HOURS/EMERGENCY CARE AND TREATMENT will incur an $85.00 charge

3. Major surgery and/or hospitalization may require a 50% deposit of estimated costs.

4. A service fee of $40.00 will be charged for all RETURNED CHECKS.

Unless the amount of the check and service fees are paid within 10 working days of the certified notice, the holder of the check will assume you delivered the check with the intent to defraud, and will be turned over for prosecution.

5. Should any problem arise in the health or condition of your pet resulting from a visit to our facility, we will not be held liable or financially responsible for any care or treatment provided by another veterinarian. Hope Animal Clinic reserves the right to evaluate and treat any post-visit health concerns you may have.

You are responsible for any cost of collecting or attempting to collect unpaid debt, including attorney's fees and court costs.

I HAVE COMPLETELY READ, UNDERSTAND, AND AGREE WITH THE ABOVE STATED POLICIES AND VERIFY THAT ALL INFORMATION BELOW IS TRUE.

Billing Name*

First Last

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Signature*

Name

This field is for validation purposes and should be left unchanged.