Call today: (650) 348-8022
HOME
About us
Hospital Tour
Services
Hospital Forms
Client Registration
Drop Off Form
Resources
Pet Insurance
PHARMACY
Blog
Contact us
HOME
About us
Hospital Tour
Services
Hospital Forms
Client Registration
Drop Off Form
Resources
Pet Insurance
PHARMACY
Blog
Contact us
Peninsula Avenue Veterinary Clinic New Client Form
*
Indicates required field
Date
*
Name
*
First
Last
Driver's License
*
Date of Birth
*
The State of California requires us to report your birth date if your pet ever is prescribed a controlled substance
Email
*
Used to send vaccine reminders and lab results
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Select One
*
Cell Phone
Home Phone
Work Phone
Other Name
*
Name of co-owner or co-guardian.
Phone Number
*
Select One
*
Cell Phone
Home Phone
Work Phone
Name and contact info last veterinarian to obtain records
*
How did you hear about us?
*
Pet's name
*
Second Pet's name
*
Species and Breed
*
Color / Markings
*
Species and Breed
*
Color / Markings
*
Date of birth
*
Date of Birth
*
Choose One
*
Female
Male
Spayed / Neutered?
*
Yes
No
Unknown
Choose One
*
Female
Male
Spayed / Neutered?
*
Yes
No
Unknown
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, PAVC 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.
Submit
