New Client Registration - Brandermill Animal Hospital

Owner Name

Birthdate

Spouse/Partner/Other

Address

City

State

ZIP / Postal Code

Cell Phone

Home Phone

Work Phone

Spouse/Partner/Other Phone

Spouse/Partner/Other Work Phone

Names of all people, including family members who have permission to authorize care/treatment of your pet(s).

Emergency Contact

Emergency Contact Phone Number

Did one of our clients refer you to us?

Yes No

If yes, who can we thank?

If no, how did you first hear about our hospital?

Pet's Name

Pet Age

Species

Breed

Sex

Color

Microchip Number

Any past medical problems or previous surgeries?

Temperament: Has your pet ever bitten anyone? Is there anything else we should know about their temperament?

Yes No Other

Please list any additional pets by Name, Age, Species, Breed, Sex and Color:

Has your pet ever seen another veterinarian?

Yes No

Name and phone # of previous Veterinarian or Hospital for vaccination/medical history on your pet(s):

You may upload pet records here:

Please note that we must receive medical history at least 48 hours prior to the appointment. If records are not received, we will contact you to reschedule the appointment.

Photo and Sharing Authorization: We love treating your pets and enjoy the time you allow us to spend with them. On occasion, we would like to capture these moments in photo/video. These photos may be emailed to you as an update on their status/progress, used on our website, or shared on social media sites such as Facebook. Do you authorize us to photograph/video your pet for these purposes?

Yes No

Peanut Butter Allergy: We like to offer peanut butter to our canine patients to make their visits more positive, but we are aware that some clients have severe peanut allergies. Do you approve us giving your pet peanut butter during their visit?

Yes No

Late Policy: Please arrive at least 5 minutes prior to your appointment time for check-in. If you arrive more than 10 minutes late for your appointment you will have the option to: Drop your pet off and pick up when ready. (schedule permitting and at veterinarian discretion) Wait to be seen and have a shortened appointment time. Reschedule for another time.

Missed Appointments and Late Cancellation Policy: Please provide at least 24 hours notice if you need to cancel or reschedule your appointment. Missed appointments and late cancellations affect our ability to care for patients in need. Clients with repeated missed appointments and/or late cancellations will be required to pay a $25 per pet deposit to secure future appointments.

PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED. Due to Legal restrictions, Prescriptions cannot be returned. We accept Visa, MasterCard, Discover, American Express & Care Credit. I understand that if I do not pay this account as agreed, the account is subject to costs of collection, attorney fees, and including interest (any balance that is carried over a period of 30days will accrue a monthly finance charge of 2% or 24% per annum). If necessary, a $50.00 collection fee will be applied, plus any charges associated with the collection of the outstanding balance. Return check fee is $50.00. I understand that the hospital staff will provide an estimate of current and anticipated charges any time I request one. I am requesting that veterinary care be provided for pets presented by me or my agents. I understand that I am financially responsible for all services provided.

Signature

Printed Name

Date

New Patient/Client Registration