Pine Hollow Veterinary Services northwest PA & northeast OH

Have you been to our clinic before?

Yes

No

If so, when and under what name?

I was referred to the clinic by:

Your Name:

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Your Address:

Your address:

City

State

Zip Code

Home Phone:

Cell Phone:

Work Phone:

Date of Birth:

Email:

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SECONDARY NAMES ON ACCOUNT

Are there any other names that need to be added to this account that are authorized in the treatment decision making process and will provide financial responsibility?

Yes

No

Secondary Name on Account:

Secondary Address:

Secondary Phone:

This individual is over 18 years of age.

Yes

No

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PATIENT INFORMATION - FOR ADDITIONAL HOUSEHOLD PETS

Pet Name:

Pet Sex:

Breed:

DOB or Age:

Color:

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Pet Name:

Pet Sex:

DOB or Age:

Breed:

Color:

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Pet Name:

Pet Sex:

Breed:

DOB or Age:

Color:

Previous Veterinarian where past records may be obtained if necessary:

I consent the release of my pet's medical information to Western Reserve Animal Clinic.

I prefer pet health reminders be sent by:

E-mail

Postcard

Both

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STATEMENT OF GOODWILL

I am 18 years of age or older and take on the financial responsibility of the care of this animal or any animal that is listed under my account at Western Reserve Animal Clinic.

I assume responsibility for all charges incurred in the care of this pet(s) that I have treated at Western Reserve Animal Clinic. I hereby authorize treatment as considered necessary. I also understand that these charges will be paid in full at the time of service.

I understand that payment is due at the time of service and that accepted forms of payment are: Cash, Check, Money Order, Care Credit, Scratchpay, Visa, Mastercard & Discover. I also understand that checks will not be held or post dated for payments.

A copy of my driver’s license has been given for identity purposes & if I write a check.

My driver's license # is:

My driver's license expires on:

I understand that me or my pet(s) may be photographed or filmed while at the premise and I give permission to the clinic and all their affiliates to use any and all photos, video footage, written material and/or video streaming for promotional, sales, publicity and advertising purposes for all media including the internet.

Yes

No

Initial

Typing my name below indicates my signature stating that I agree with all initialed items in this document.

Date:

New Client Registration Form

PET MEDICAL HISTORY FORM