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
Co-owner's Name & Contact #
Name
First Last
Phone
How did you find out about our practice?
- Clinic Location
- Personal Referral
- Internet Search / Website
- Yellow Pages
- Clinic Sign
- Newspaper / Print Media
- Other
If Other, please specify:
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*
or if other 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
THANK YOU FOR CHOOSING BENNETTS CREEK VETERINARY CARE! PAYMENT IS DUE WHEN SERVICES ARE RENDERED BY: CASH, VISA, MC, DISCOVER, AMEX. NO PERSONAL CHECKS OR CARE CREDIT ACCEPTED

WE RESERVE THE RIGHT TO CHARGE A MISSED APPOINTMENT FEE FOR ALL MISSED APPOINTMENTS OR THOSE WITHOUT PROPER CANCELLATION NOTICE (24 HOURS).

WE ALSO RESERVE THE RIGHT TO CANCEL APPOINTMENT PRIVILEGES FOR THOSE THAT FREQUENTLY MISS APPOINTMENTS. A $30 CHARGE IS MADE FOR RETURNED CHECKS. FINANCE CHARGES ARE APPLIED TO UNPAID BALANCES OVER 30 DAYS AT THE RATE OF 2% PER MONTH, WHICH IS AN ANNUAL PERCENTAGE RATE OF 24% WITH THE ADDITION OF ANY/ ALL COLLECTION AGENCY, COURT COST, OR ATTORNEY FEES NECESSARY TO COLLECT THE FULL AMOUNT DUE TO BENNETTS CREEK VETERINARY CARE WITHOUT ANY RELIEF WHATSOEVER FROM VALUATION OR APPRAISMENT LAWS (THESE FEES ARE APPROXIMATELY 30-50% OF THE ACCOUNT).

New Client Registration Form

Owner's Name

Co-owner's Name & Contact #

Pet Information

LOCATION

HOURS OF OPERATION

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