New Client Registration
Owner Information
First Name
Last Name
Co-Owner
Street Address
City
State
Zip Code
Phone (Home)
Phone (Cell)
Phone (Emergency)
Email
Pet Information
Pet's Name
Species
Dog
Cat
Bird
Other
Breed
Color
Date of Birth
If Unknown, approximate Age
Gender
Male
Female
Spayed/Neutered
Yes
No
Microchip Number
Pet Insurance Carrier
Previous Veterinarian
Phone Number
Please describe any issues or concerns you have about your pet's health
How did you hear about our hospital?
Drive by
Facebook
Petland
Lil Rascals
Other/Referral
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 Policy
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)
Register
looking to
join our team?
We’re looking for veterinary technicians and receptionists with our growth and expansion
Email your resume to
lindsay@gracevets.com
