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Client Registration:
(If you're a current client and you've had no changes since your last visit, you'll only need to enter your name in this section.)
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Owner(s) name(s):
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Address:
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Street City State Zip
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Phone Numbers:
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Home Phone Work Phone Cell Phone
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Email Address:
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Your Employer:
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Your Spouse's/Partner's Employer:
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Patient Registration:
If there's any information you don't know, just leave that portion blank.
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Pet's Name:
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Breed:
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Color:
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Birthdate:
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Sex:
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From where did you obtain your pet, and at what age?
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How is your pet kept?
(Hold down the Ctrl button
for multiple selections)
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Contact with
other animals?
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Taken to kennel
and/or groomer?
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Type of food:
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Treats:
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Table Food?
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Vaccination History: If you have vaccine records, please bring them with you for your pet's first visit. Otherwise,
we can contact your other veterinarian(s) for that information.
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Who may we contact for your pet's vaccine history and medical records?
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Please list any previous health problems/concerns:
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Reason for this visit?
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If you have already scheduled an
appointment with us, when is your
appointment?
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NOTICE:
South Huntington Animal Hospital requires a valid driver's license or government issued photo
ID to fully activate your status as a client. Also, South Huntington Animal Hospital requires payment
IN FULL at time services are rendered. We do not extend any credit, nor do we offer any type of
payment plan or billing service. Upon request, we will be happy to discuss any and all charges and
potential charges before your pet is treated. For your convenience, we accept cash, personal
check, Visa, Mastercard, Discover, and Care Credit.
By clicking below and submitting this form, you agree that you have read and fully understand this
notice.
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Please submit a separate form for each pet. However, you'll only need to enter your name again in the Client Registration section.
We genuinely appreciate the trust you place in us by allowing us to care for your loved ones.
THANK YOU!
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