New Client Registration Form

Client Information

Primary Adult Owner's Name (Must be 18 or older, legally responsible for pet)*

First Last

Date of Birth (MM/DD/YYYY, required for dispensing certain medications)*

Spouse/Partner/Other’s Name*

First Last

Their Cell #*

Is this person allowed to make medical decisions regarding your pet(s)?*

Yes
No

Is there anyone in the home under the age of 18 that is considered to be the PRIMARY caretaker for an animal in your home? If yes, Name/Age/DOB and Animal cared for by this person.*

Address*

Street Address Address Line 2 City State ZIP Code

Cell Phone*

May we text you to communicate with you about your pet(s)?*

Yes
No

Primary E-mail Address (For forms and medical information)*

Home, Work, or Other # where you may be reached*

Type? Hours?*

Place of Employment*

Occupation*

How did you find us?*

Event (Which One?)

Name of person who referred you? (We give $ credit to clients for referrals!)

Additional Information

Briefly describe which pet you have with you and the reason for your visit today (wellness, establish relationship, sick visit, etc.).*

In an effort to make everyone as safe and comfortable as possible, does anyone in the home have SEVERE allergies or PHOBIAS that we should be aware of prior to your visit (peanuts, cats, birds, etc.)?*

Yes
No

If yes, please explain

Authorizations

Emergency Contact - In the event that you become incapacitated or cannot be reached and an emergency occurs, whom may we contact? This should be someone that you permit to make medical decisions regarding you or your pet(s).*

First Last

Relationship*

Phone*

Other Phone (if applicable)

Consent*

I authorize the veterinarian(s) at Middle Creek Veterinary Hospital to handle, examine, prescribe for, or medically treat and/or care for my pet(s).

Consent*

I understand that the hospital can be scary for many animals. When animals are scared, they sometimes bite or scratch. Because of this and other liabilities, I will not be allowed to restrain my own pet during medical care.

Consent*

I assume responsibility for any and all charges incurred during and surrounding the care of my animal(s).

Consent*

I understand that any outstanding balance must be paid at the time of the appointment or release of the animal from the hospital.

Consent*

I agree to pay a deposit prior to surgery or hospitalization if necessary.

Consent*

Middle Creek Veterinary Hospital may take photos or videos of my animal(s) during their visit. These photos or videos may be used for education or marketing purposes. We respect your privacy and will NEVER share your personal information on social media. This includes names, private medical information, or faces of humans (especially children).

Name*

First Last

Date*

Monday	9:00am – 5:00pm
Tuesday	10:00am – 7:00pm
Wednesday	9:00am – 5:00pm
Thursday	10:00am – 7:00pm
Friday	9:00am – 5:00pm
Saturday	By Appointment Only
Sunday	Closed

Client Information

Additional Information

Authorizations

Contact Us

Hours of Operation

Emergency Info