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.

Client’s full name

Phone

Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Confirm Email

Co-Owner Full name

Phone

If Personal Referral, is there someone we can thank for this referral?

Full Name of previous Veterinarian

Phone number of previous Veterinarian

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.

Yes No

Other Pets:

Any previous serious illness or surgeries?

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.

I understand and agree

Client’s Full Name