New Client Form – Hoffman Animal Hospital

New Client Registration Form

Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.

Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.

Owner's Name
Name*
First Last
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Enter Email Confirm Email
Co-Owner's Name & Contact #
Name
First Last
Phone
How did you find out about our practice?*
- Google
- Hoffman Animal Hospital Website
- Facebook
- Open House
- SPCA
- SPCA Walk
- Community Event
- Strawberry Festival
- Cape Fun Run
- Referral Vet
- Drove By
- Friend
- Other
If Personal Referral, is there someone we can thank for this referral?
Name of previous Veterinarian
First Last
Phone number of previous Veterinarian
Pet Information
Pet's Name*
Species*
or if other species
Breed (if known)
Color
Date of Birth or Age (if known)
Special Identification (tattoo, microchip, etc.)
Sex*
I agree to allow Hoffman Animal Hospital to release portions of my pet(s) medical history and record, including personal recollections, radiographs, photographs, videotape images, or other images to the below media entities on social media, blogs, marketing materials, and educational information.*
Other Pets:
Any previous serious illness or surgeries?
Any allergies to vaccinations or medications?
Is your pet on any special diets or medications?
Would you like to be present during treatment of your pet?
- Yes
- No
All fees are due at the time services are rendered and I agree to pay the balance in full. If not paid in full, I agree to pay all costs associated with collection. I agree and understand that by typing my name below, all electronic signatures are the legal equivalent of my signature and I consent to be legally bound to this agreement.
Name*
First Last