Talega Animal Hospital - New Client Registration Form

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Name
Email Address
Home Address
Apt #
CA Zip
Cell #
Home Phone #
Work #
2
Mailing Address
3
Please Select
Please Select
Cellphone
Home Number
Work Number
How do you prefer to be contacted?
Occupation
Driver’s License Number (State)
Driver’s License Number
Significant Other
Best number to reach
4
Do you have a friend, relative, neighbor or pet sitter, who is authorized to bring in pet(s) and make treatment decisions in your absence?
Name
Relationship
Phone Number
5
Who do we thank for sending you to us?
Friend / Relative
Pet Business
Please Select
Please Select
Drove By
Yelp
Google
Yahoo
Military Brochure or Military Connection
Animal Shelter
Neighborhood Mailer or Brochure
Our Website
Other
Select from the following
Please Specify, If Other
6
May we take pictures of your pet during their stay? If you sign a release form, we may use their likeness(es) in our social media activities as well as a form of contact for you. (updates, etc.)
YES
NO
Tell me more
7
NAME
SPECIES (DOG, CAT RABBIT, ETC)
BREED
SEX
SPAYED OR NEUTERED
DATE OF BIRTH
COLOR
PET #1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Male
Female
Row 0, Column 3
Yes
No
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
PET #2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Male
Female
Row 1, Column 3
Yes
No
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
PET #3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Male
Female
Row 2, Column 3
Yes
No
Row 2, Column 4
Row 2, Column 5
Row 2, Column 6
PET #4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Male
Female
Row 3, Column 3
Yes
No
Row 3, Column 4
Row 3, Column 5
Row 3, Column 6
PET #1
PET #2
PET #3
PET #4
NAME
Row 0, Column 0
SPECIES (DOG, CAT RABBIT, ETC)
Row 0, Column 1
BREED
Row 0, Column 2
SEX
Male
Female
Row 0, Column 3
SPAYED OR NEUTERED
Yes
No
Row 0, Column 4
DATE OF BIRTH
Row 0, Column 5
COLOR
Row 0, Column 6
NAME
Row 1, Column 0
SPECIES (DOG, CAT RABBIT, ETC)
Row 1, Column 1
BREED
Row 1, Column 2
SEX
Male
Female
Row 1, Column 3
SPAYED OR NEUTERED
Yes
No
Row 1, Column 4
DATE OF BIRTH
Row 1, Column 5
COLOR
Row 1, Column 6
NAME
Row 2, Column 0
SPECIES (DOG, CAT RABBIT, ETC)
Row 2, Column 1
BREED
Row 2, Column 2
SEX
Male
Female
Row 2, Column 3
SPAYED OR NEUTERED
Yes
No
Row 2, Column 4
DATE OF BIRTH
Row 2, Column 5
COLOR
Row 2, Column 6
NAME
Row 3, Column 0
SPECIES (DOG, CAT RABBIT, ETC)
Row 3, Column 1
BREED
Row 3, Column 2
SEX
Male
Female
Row 3, Column 3
SPAYED OR NEUTERED
Yes
No
Row 3, Column 4
DATE OF BIRTH
Row 3, Column 5
COLOR
Row 3, Column 6
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I understand that payment is required in full at the time services are rendered. WE DO NOT BILL.

I hereby authorize Talega Lantern Animal Hospital to render medical & surgical care for my pet(s) as deemed necessary by the veterinarian.

I understand I may be asked to leave a deposit before surgical procedures and lengthy boarding reservations.

I understand Talega Lantern Animal Hospital does not accept out-of-state checks or offer payment plans.

Veterinary service during nighttime hours, some daytime hours, and/or weekends, is provided at the discretion of the veterinarian in charge. Continuous presence of personnel may not be provided during these hours.

I understand personal items (blankets, toys, etc.) may not be returned if left at Talega Lantern Animal Hospital.

I understand that fecal testing for parasites is recommended every 6 months for my pet and according to the Centers for Disease Control and Prevention feline and canine parasites can be transmitted to humans and can cause potentially serious health problems.

I understand that eliminating intestinal parasites from my pet is essential and is extremely important for the health of my pet(s) and my family.

Declaration: If my account should become delinquent, I am responsible for all collection costs & attorney fees. A finance charge of 1.5% per month (or a $5.00 monthly service charge, whichever is greater), plus a $3.00 monthly billing fee is due on all balances owed over 30 days. My signature indicates I understand these policies and agree to them.
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Signature* This field is required.
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Date* This field is required.
Date
Year
Month
Day
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Talega Animal Hospital Privacy Policy: We do not divulge client information except as required by law.
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