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New Patient Welcome Form
Eddie Coutras
2020-03-03T20:06:20+00:00
Client & Pet Registration Form
Client & Pet Registration Form
Step
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Owner Name
*
Co-Owner Name
Address
*
Street Address
Address Line 2
City
Alabama
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Colorado
Connecticut
Delaware
District of Columbia
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U.S. Virgin Islands
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Virginia
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
*
Owner Home Phone
*
Co-Owner Home Phone
*
Owner Work Phone
Co-Owner Work Phone
Name of Previous Clinic
Phone Number of Previous Clinic
Communication Preference
*
Email
Text
Call
Senior (Are you over 62 years of age?)
Yes
No
Recommended by Whom?
Place of Employment
Number of Pets
*
Pet #1
Pet #1
*
Dog
Cat
Rabbit
Rat
Mouse
Guinea Pig
Ferret
Pet #1 Name
*
Pet #1 Breed
*
Pet #1 Microchip Number
Pet #1 Date of Birth
*
MM slash DD slash YYYY
Pet #1 Color
*
Pet #1 Sex
Male
Female
Pet #1 Spayed or Neutered
Spayed
Neutered
Pet #2
Pet #2
*
Dog
Cat
Rabbit
Rat
Mouse
Guinea Pig
Ferret
Pet #2 Name
*
Pet #2 Breed
*
Pet #2 Microchip Number
Pet #2 Date of Birth
*
MM slash DD slash YYYY
Pet #2 Color
*
Pet #2 Sex
Male
Female
Pet #2 Spayed or Neutered
Spayed
Neutered
Pet #3
Pet #3
*
Dog
Cat
Rabbit
Rat
Mouse
Guinea Pig
Ferret
Pet #3 Name
*
Pet #3 Breed
*
Pet #3 Microchip Number
Pet #3 Date of Birth
*
MM slash DD slash YYYY
Pet #3 Color
*
Pet #3 Sex
Male
Female
Pet #3 Spayed or Neutered
Spayed
Neutered
Consent & Agreement
*
By checking the box, I agree to the following....
I/we hereby authorize the veterinarians to examine, prescribe for, or treat my pets (s). I/we assume full responsibility for all charges incurred in the care of this/these animal(s). I/we also understand that these charges will be paid in full at the time of release and that a deposit may be required for certain surgical treatments or other procedures. No refunds, chargebacks or cancellations once services are performed.
Pet Restraint Policy
For legal and safety reasons, it is AAAH's policy that a trained staff member or veterinarian will restrain your pet during any/all exams, testing and procedures being performed. It is a non-waiving policy. Owners, children, family members, friends, or caretakers MAY NOT hold or restrain their own pet while an exam is being performed. Please do not place your face or hands near an animal's face during an exam, even if you think you are calming or helping your pet. Rarely we may require a muzzle restraint for an aggressive pet. This is for the safety of the staff and veterinarian as well as that of the pet to receive a thorough exam. If you perceive your pet to be anxious or stressed before beginning an exam, a suitable calming medication may be given orally or by an injection. The health and safety of our staff, clients, and our patients is of the most importance. We will use all/any precautions to ensure this. Thank you for your understanding.
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