Client Registration

Peninsula Avenue Veterinary Clinic New Client Form

* Indicates required field

Date *

Name *

First

Last

Driver's License *

Date of Birth *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Select One *

Co-owner Name *

Phone Number *

Select One *

Name and contact info 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 *

Choose One *

Female Intact Female Spayed Male Intact Male Neutered

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, 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. I AGREE TO PREPAY THE FIRST OFFICE CALL FOR MY PETS ($102). I UNDERSTAND THAT IF I CANCEL WITHOUT 24 HOURS NOTICE, THAT I FORFEIT THIS FEE. I also authorize the sharing of medical records, including radiographs, with other hospitals and pet insurance companies that request them.

PLEASE ENTER YOUR FULL NAME AND CLICK SUBMIT TO ACKNOWLEDGE AGREEMENT TO THE TERMS AND CONDITIONS IN THE STATEMENT ABOVE *

Submit

Peninsula Avenue Veterinary Clinic New Client Form

LOCATION

HOURS

CONTACT US

Peninsula Avenue Veterinary Clinic New Client Form​

LOCATION

HOURS

CONTACT US

Peninsula Avenue Veterinary Clinic New Client Form