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Veterinarians in Los Angeles | Beverly Robertson Veterinary Clinic
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Beverlywood Plaza 1800 S. Robertson Blvd #8 Los Angeles, CA 90035 info@beverlyrobertsonvet.com
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   New Client Registration Form
 Home » 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


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?Clinic Location
Personal Referral
Internet Search / Website
By A Groomer
Yelp
Facebook
Radio
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)

Date Format: MM slash DD slash YYYY

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.

 














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 Let’s work together to keep your beloved furry family member happy and healthy! 

Contact Us Today
Connect With Us! 310-464-0264 info@beverlyrobertsonvet.com Fax: 310-730-6839
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