New Patient Registration Form

CONTACT INFORMATION

Full Name *

Phone Number

Address *

City *

Province *

Postal Code *

Email Address *

Spouse/Co-Owner Name

Spouse/Co-Owner Phone Number

Emergency Contact (Full Name) *

Emergency Contact Phone Number *

Pet Insurance Provider

Insurance Policy #

Cell Number for Text Reminders

I agree to receive vaccination reminders, hospital information and other communications from Deer Park Pet Hospital. I may withdraw my consent at any time.

PET HEALTH HISTORY

Pet's Name *

Species *

Breed *

Colour *

Date of Birth *

Sex *

Pet's Current Medications *

Pet's Current Diet *

AUTHORIZATION

PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE PERFORMED. In admitting my pet(s) for diagnostic, treatment, or surgery, I authorize the veterinarians of Deer Park Pet Hospital, and their support staff, to perform such treatment and/or perform such diagnostic or surgical procedures as deemed necessary. It is understood that an estimate of charges will be given for services at the client’s request. No guarantee or assurance can be made as to the results that may be obtained. I understand that a deposit of 50% may be required before services are performed and I assume full financial responsibility for all charges incurred by my pet. I realize that these charges may exceed a given estimate if complications arise. I understand that I will be contacted prior to treatment, if possible, should complications occur.

Signature *

Date *

Today

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

New Patient Registration Form

CONTACT INFORMATION

PET HEALTH HISTORY

AUTHORIZATION

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