New Client Registration Form "*" indicates required fields Client Name* First Last Spouse/Partner Name First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Home PhoneWork PhoneList all persons (over 18yrs old) that have your permission to make medical decisions in your absence:*Email* Please tell us your preferred method of communication regarding your pet for labwork and doctor contact* Cell Phone Home Phone Work Phone How were you referred to us:* Friend/Family Member Shelter or rescue organization Other Please specify*Patient InformationName*Breed*Color*Species*DOB*Sex* Male Female Spayed Neutered AllergiesMedical HistoryPlease enter date when given*RABIESDHLPP/FVRCPBORDETELLAHEARTWORM TESTFECAL TESTMICROCHIPOther Pets in HouseholdPet’s NameColorSpeciesBreedAgeSexAltered? Y/N Add RemoveHelping Paws Animal Hospitals would like you to be aware that all fees are due at the time services are rendered. If your pet is hospitalized, 100 % prepayment of the estimate amount is due upon hospitalization. We are a cashless facility and accept Mastercard, Visa, American Express, Discover, and Debit cards. There is a $25.00 fee for all returned checks. We must also state that if your account becomes delinquent, it may be necessary to send the account to a collection agency and you will be responsible for any collection fees, legal and/or courts costs. Helping Paws Animal Hospitals may take photographs of your pet for identification purposes or for medical progress reports, which shall become part of the medical record. By signing this form, you acknowledge that you are the owner of the pet stated above and you have the right to authorize or deny any treatment for this pet. You understand that no guarantee can be made as to the outcome of veterinary treatment for your pet. By signing this you are stating that you are over 18 years of age and are financially responsible for all charges incurred for patients on your account. Signature*Date* MM slash DD slash YYYY Δ
