Client Registration

Peninsula Avenue Veterinary Clinic New Client Form

* Indicates required field

Date *

Name *

First

Last

Driver's License *

Date of Birth *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Co-owner's Name *

Co-owner's Phone Number *

Co-owner's Email *

Name and contact info of last veterinarian to obtain records *

How did you hear about us? / Who should we thank for the referral? *

Pet's name *

Species and Breed *

Color / Markings *

Date of birth / Age *

Choose One *

Female Intact Female Spayed Male Intact Male Neutered

Second Pet's Name *

Second Pet's Species and Breed *

Second Pet's Color / Markings *

Second Pet's Date of Birth / Age *

Choose One *

Female Intact Female Spayed Male Intact Male Neutered

PLEASE ENTER YOUR FULL NAME AND BY SUBMITTING THE FORM I AGREE TO THE TERMS BELOW: I am the owner or authorized agent of the pet identified herein, hereby consent to the examination of my pet by staff veterinarians at Peninsula Avenue Veterinary Clinic and after consultation with me to prescribe for, treat, hospitalize, anesthetize or perform surgery on my animal. I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with my attending veterinarian before the procedure is initiated. Should some unexpected life-saving emergency care be required, Peninsula Ave Veterinary Clinic staff has my permission to provide such treatment and I agree to pay for such care I understand that an estimate of the costs for veterinary services will be provided to me and that I am encouraged to discuss all fees attendant to such care before services are rendered and during my pet's admission. I agree to assume financial responsibility for the balance of ALL services rendered on a cash, credit card, or check basis at the time my pet is discharged from the hospital. In the event of an open balance, I agree to pay a monthly billing and financing fee equal to 1.5% of the unpaid balance. By registering for Peninsula Ave Veterinary Clinic, you authorize us to charge the provided payment method for the agreed-upon fees. You agree to contact us directly to resolve any billing discrepancies before initiating a dispute with your financial institution. You agree that you will not file a chargeback or payment reversal request with your credit card company or bank for legitimate charges that comply with our Terms of Service. If you believe a charge was made in error, you must notify us within 10 days of the transaction. In the event an unauthorized chargeback or reversal is filed, Peninsula Ave Veterinary Clinic reserves the right to immediately suspend or terminate your account and client registration and charge a $50 administrative fee.I I authorize the sharing of medical records, including radiographs, with other hospitals and pet insurance companies that request them. I agree to prepay the first office visit for my pet. I am aware office visits will be charged if I do not cancel 24 hours prior to the scheduled appointment. *

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Peninsula Avenue Veterinary Clinic New Client Form

LOCATION

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CONTACT US

Peninsula Avenue Veterinary Clinic New Client Form​

LOCATION

HOURS

CONTACT US

Peninsula Avenue Veterinary Clinic New Client Form