myvetavh.com - New Patient/Client Registration Form

New Patient/Client Registration Form
Owner’s Information
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date *

Month Day Year
Date
Owner’s Driver’s License # & State *
Daytime Phone # *
Please enter a valid phone number.
Is it

Primary
Evening Phone # *
Please enter a valid phone number.
Is it

Primary
Cell Phone # *
Please enter a valid phone number.
Is it

Primary
Email Address *

Confirmation Email Confirm Email
Co-Owner’s Name *
Phone Number *
Please enter a valid phone number.
How did you find out about our practice? *

Google / Internet Search Social Media Clinic Location / Signage Personal Referral Other
Personal Referral: Someone we should thank?
What Social Media Platforms do you use? *

Facebook Instagram Tik Tok Twitter Snapchat Pinterest I DONOT use any platforms
Pet’s Information
Pet’s Name *
Pet’s Name at the Time of Adoption *
(applies to pets adopted from Woof Gang Rescue)
Species *
Sex *
Breed *
Color/Markings *
Date of Birth / Age *
Microchip *

Not microchipped Type Any Other
Medical Information
Previous Veterinary Practice (is any)
Do we have your permission to collect records? *

Yes No
Is your pet on any medication or supplements? Please list: *
Please list:
What type of food does your pet eat? Please List *
Please list:
Does your pet have any allergies or drug reactions? Please List: *
Please list:
Are there any current or past medical conditions we should be aware of? *

Yes No
If yes, please explain: *
Are there any other pets in the home? *

Yes No
If yes, please list: *
Do you have another pet you would like to register with our practice today? *

Yes No
2nd Pet
Is your pet on any medication or supplements? Please list: *
Please list:
What type of food does your pet eat? Please List *
Please list:
Does your pet have any allergies or drug reactions? Please List: *
Please list:
Are there any current or past medical conditions we should be aware of?

Yes No
If yes, please explain: *
Are there any other pets in the home? *

Yes No
If yes, please list: *
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 *

YES! You have my permission No, I do not consent
Pet Health Savings Plan
Say Goodbye to full price with our In-House Savings Plan!
Not only will you save 20% on every invoice at every visit, your pet will also receive a FREE Rabies vaccine!
*

YES! Tell me more. I’d like more information on your Pet Health Savings Plan No Thank You. I am not interested in learning more about the plan at this time.
Treatment Consent
Type a question *

Clear
Date *

Month Day Year
Date
Should be Empty:

New Patient/Client Registration Form

Owner’s Information

Pet’s Information

Medical Information

2nd Pet

Photo Consent:

Pet Health Savings Plan

Treatment Consent