New Client Registration
Date of Birth
If Unknown, approximate Age
Pet Insurance Carrier
Please describe any issues or concerns you have about your pet's health
How did you hear about our hospital?
Medical Release Consent and Social Media Consent
(Please initial below)
I authorize Grace Veterinary Center to release records upon request to boarding, other medical offices, etc. when needed.
I authorize Grace Veterinary Center to share photos of my pet for puposes of advertising and social media. Please note your photo will not be sold to a third party
Payment is due at time of service. This policy helps to control costs on which we base our fees. A 50% deposit may be required for day admission cases and procedures, including, but not limited to: surgery, dentistry, and hospitalization. We accept cash, check, credit, debit, Care Credit, and Scratch Pay. We do not carry open accounts and hope the above alternatives are convenient for you.
Financial Agreement and Authorization
I hereby authorize the veterinarian and staff at Grace Veterinary Center to examine, prescribe for, and treat my animal. I assume responsibility for all charges incurred in the care of my animal. I agree to pay any costs and charges necessary for the collection of any amount not paid when due.
Signature (Please type full name)