Client Registration Form

Owner's Name *

Email *

Co-owner/Spouse

Co-owner/Spouse Email

These e-mail addresses are to be used by PHVMC only for the purposes of patient care updates, appointment and vaccinations reminders, hospital newsletter, special announcements and test results. They will never be shared with outside parties nor sold to outside vendors. Please help us be environmentally friendly by using less paper. You can elect to opt-out of receiving our newsletter. *

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I prefer to receive general reminders by: *

Email
Mail

I prefer to receive appointment reminders by: *

Email
Mail
Phone

If my pet is hospitalized or admitted for a procedure, I would prefer to receive updates by: *

Email
Phone Call
Text Message

Address *

Address Line 1

City

State

Zip Code

Owner Home Phone

Owner Cell Phone *

Owner Work Phone

Co-owner/Spouse Home Phone

Co-owner/Spouse Cell Phone

Co-owner/Spouse Work Phone

Primary Contact Number for Owner: *

Home
Cell
Work

Primary Contact Number for Co-owner:

Home
Cell
Work

Is it okay to attempt to reach Owner at Work number?

Yes
No

Is it okay to attempt to reach Co-owner at Work number?

Yes
No

How did you find out about Park Hill Veterinary Medical Center? *

Whom may we thank?

Please explain

What veterinary facility can we contact for your pet(s) medical history?

Consent for Treatment: I, the undersigned owner or owner’s agent, of the pet/s identified on the pet information sheet/s, acknowledge and confirm the information here and on additional pages, is accurate and correct to the best of my understanding. I, the undersigned owner or owner’s agent, of the pet/s identified on the pet information sheet/s, certify that I am over eighteen (18) years of age and thereby consent to the examination of my pet by the veterinarians and staff of Park Hill Veterinary Medical Center PC, and, after consultation with me, to prescribe medications for, treat, hospitalize, anesthetize and/or perform surgery on my pet. I understand that some risks always exist with the medical treatment of my pet, including anesthesia and surgery and that I am encouraged to discuss in detail my concerns and understand the risks with my attending veterinarian before treatment is initiated. Should unexpected life-saving emergency care be required and my attending veterinarian is unable to reach me, Park Hilll Veterinary Medical Center PC has my permission to provide such treatment and I agree to pay for such care. I understand that 24-hours continuous supervision of my pet is not provided if my pet is to be hospitalized. *

I have read and understand

Financial Responsibility: I understand that an estimation of treatment costs will be provided for all anesthetic/surgical procedures and also upon request for anything else. Please know that you are always free to discuss fees before services are rendered and during your pet’s on-going medical treatment. If my pet is admitted to Park Hill Veterinary Medical Center PC for hospitalization for any reason, I understand that I may be required to pay a deposit of 50% of the estimated fees and assume financial responsibility for the remaining balance when my pet is discharged. ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED except as previously described — we accept cash, checks, VISA, MasterCard, Discover, American Express and Citi Health Card. There will be a $25 fee for any check returned unpaid. *

I have read and understand

Abandonment: Any animal left without owner involvement (5 days written notice via certified mail) is subject to abandonment rights and shelter authorities, with all charges still pending and the owner remaining responsible for all charges plus interest. Customer agrees to pay a finance charge of one and one-half percent (1.5%) per month on all amounts due and owing to Park Hill Veterinary Medical Center PC. *

I have read and understand

Other Permissions: Photographs & Video — with my signature below, I allow Park Hill Veterinary Medical Center PC to use photographs or videos of my pet for educational or promotional purposes in any type of media, including its website. I understand that I will not be paid or rewarded for providing this authorization. Should Park Hill Veterinary Medical Center PC wish to identify my pet or myself by name, they will seek my express and written permission for this use. *

I have read and understand

Digital Signature *

(Please type your name as confirmation you have read and agree to the terms stated above)

Date *

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