New Client Registration Form Welcome to The Village Animal Hospital! Please fill out this form in its entirety to help us prepare for your upcoming visit. Please note that we require New Client Registration Forms to be completed 24 hours PRIOR to your first appointment. If we do not receive this form 24 hours prior to your appointment, WE WILL NEED TO CANCEL AND RESCHEDULE YOUR APPOINTMENT. Client Information Pet Owner First Name Last Name Address Street Address Address Line 2 City State --- Please select ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary Phone By providing your phone number, you are agreeing to receive calls and text messages regarding your pet's health and medical reminders from The Village Animal Hospital. You can opt out at any time. Secondary Phone Email By providing your email address, you are agreeing to receive emails regarding your pet's health, medical reminders and news about The Village Animal Hospital. Owner Date of Birth How did you find us? --- Please select ---Internet SearchSocial MediaYelpReferralOther Is there a secondary owner or spouse we should add for this pet(s)? Yes No Spouse/Secondary Owner First Name Last Name Spouse/Secondary Owner Phone Number Spouse/Secondary Owner Email Pet Information Please complete all information below. Pet Name Species Canine (Dog) Feline (Cat) Other Breed Date of Birth (or approximate) Color Sex Male Female Is your pet spayed or neutered? Yes No Microchip Number (if known) Has this pet been a patient of another veterinary clinic(s)? Yes No Please upload previous veterinary records Max. file size: 32 MB. If you do not have previous records to upload, please tell us who to contact to retrieve these records: Do you have a second pet to add? Yes No Second Pet Information Please complete all information below. Pet Name Species Canine (Dog) Feline (Cat) Other Breed Date of Birth (or approximate) Color Sex Male Female Is your pet spayed or neutered? Yes No Microchip Number (if known) Has this pet been a patient of another veterinary clinic(s)? Yes No Please upload previous veterinary records Max. file size: 32 MB. If you do not have previous records to upload, please tell us who to contact to retrieve these records: Do you have a third pet to add? Yes No Third Pet Information Please complete all information below. Pet Name Species Canine (Dog) Feline (Cat) Other Breed Date of Birth (or approximate) Color Sex Male Female Is your pet spayed or neutered? Yes No Microchip Number (if known) Has this pet been a patient of another veterinary clinic(s)? Yes No Please upload previous veterinary records Max. file size: 32 MB. If you do not have previous records to upload, please tell us who to contact to retrieve these records: Social Media Release The Village Animal Hospital occasionally features client pets on our social media accounts. By opting in, you give your consent for your pet(s) to be featured. We will never post medical or case photos or information without additional consent from you. Social Media Consent Yes, I consent. No, I do not want my pet(s) featured on social media or other digital or print media. Policy Confirmation Policy Agreement By checking this box, I indicate that as the owner of this pet(s) I read, understand and agree to The Village Animal Hospital's Financial, Late and Cancellation policies. Consent to Treat As the owner of this pet(s), I hereby authorize The Village Animal Hospital to render medical care for my pet(s) as deemed necessary by a veterinarian. I understand no guarantee can be given to the outcome of medical treatments and/or surgeries and take it as my responsibility to comprehend any risks involved. I authorize The Village Animal Hospital to render care and provide the supplies and medications necessary, knowing that in some cases certain drugs may be used off-label. I agree to pay for the cost of all services to which I consent to by written or verbal estimate. I understand that a deposit is required before diagnostics and treatments can be initiated and that payment in full is required prior to discharge of the patient from The Village Animal Hospital. Submit