New Client Registration Form

Owner's Name

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Day-Time Phone*

Evening Phone

Mobile Phone

Email*

Enter Email Confirm Email

DOB

Co-owner's Name & Contact #

Name

First Last

Phone

How did you find out about our practice?

Groomers Name?

First Last

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

Please use this area to give us any other relevant information about yourself or your family

Pet Information

Pet's Name*

Species*

Breed (if known)

Color

Date of Birth or Age (if known)*

Special Identification (tattoo, microchip, etc.)

Sex

Previous Veterinary Practice (if any)

Previous Veterinarian (if any)

Date of last vaccines (if known)

What vaccines were given at this time

Is your pet on any medication or supplement?

Yes
No

If Yes, please list the medication or supplement

What food does your pet eat?

Does your pet have allergies or drug reactions?

Yes
No

If Yes, please list the allergies and reactions

Are there any current or past medical conditions of which we should be aware?

Yes
No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Please use the following box to give us any other relevant information about your pet

What is the best way to remind you regarding your pet's vaccinations and annual checkup?*

Mail
Email
Phone

Consent*

I hereby authorize the veterinarian to examine, prescribe for, and/or treat the above-described pet. I assume full responsibility for all charges incurred for the care of this animal. I also understand these charges will be paid at the time of release and that a deposit may be required for hospitalization and surgeries. I understand that it is the policy of Beverly Robertson Veterinary Clinic no to refund any medication that is prescribed by the veterinarian once it has left the clinic.

Consent*

I, (cardholder’s name typed below), authorize Beverly Robertson Veterinary Clinic to charge the following credit card for the sole purpose of services (visits, procedures/surgeries and or recurring charges, medications) rendered on my pet(s) named below

Cardholder Name*

First Last

Pet Name*

Credit Card Info

Credit Card Type*

Cardholder's Name*

Credit Card Number*

Verify Credit Card Number*

Expiry Date*

Billing Address on the Card*

Email Address*

Consent*

I understand this form is valid up to a year unless I cancel the authorization with written notification (email) to Beverly Robertson Veterinary Clinic.

Consent*

I understand if I cancel my appointment at the day of the visit or no show for the visit, Beverly Robertson Veterinary Clinic will charge $85 cancellation or no-show fee.

Consent*

I understand all cancellation needs to be done within 24 hours of the visit via email.

New Client Registration Form

Owner's Name

Co-owner's Name & Contact #

Pet Information

Credit Card Info

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