New Client Registration Form – Chanticleer Veterinary Hospital

Owner's Name

Name*

First Last

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Day-Time Phone*

Evening Phone

Mobile Phone

Email*

Enter Email Confirm Email

Co-owner's Name & Contact #

Name

First Last

Phone

How did you find out about our practice?*

If Personal Referral, is there someone we can thank for this referral?

Please use this area to give us any other relevant information about yourself or your family

Pet Information

Pet's Name*

Species*

or if other species

Breed (if known)

Color

Date of Birth or Age (if known)

Special Identification (tattoo, microchip, etc.)

Sex

Previous Veterinary Practice (if any)

Previous Veterinarian (if any)

Date of last vaccines (if known)

Please use the following box to give us any other relevant information about your pet

Pet Photo Consent*

By checking “yes” I hereby grant Chanticleer Veterinary Hospital permission to use any photographs taken of myself or my pet, in any and all business publications, including but not limited to website entries, social media, and marketing materials without payment or any other consideration. I understand and agree that these materials will become property of Chanticleer Veterinary Hospital and will not be returned and hereby authorize to edit, alter, copy, exhibit, publish or distribute all photos for purposes of publicizing programs or for any other lawful purpose. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph. I hereby release rights to all claims, demands, and causes to action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf of my estate have or may have by reason of this authorization.

Yes
No

Hospital Policies

Our main goal is to provide quality, compassionate care for your companion. No-shows, late arrivals, and last-minute cancellations inconvenience those individuals who need access to veterinary care and prevent our staff from providing you with the attention you and your pets deserve. Please read through our hospital policies below:

Appointment Policies*

Missed Appointment Policy: Our main goal is to provide quality, compassionate care for your companion. No-shows, late arrivals, and last-minute cancellations inconvenience those individuals who need access to veterinary care and prevent our staff from providing you with the attention you and your pets deserve.

Cancellation of an appointment: A veterinary / client relationship is built on mutual trust and respect. As such, we strive to be on time for your scheduled appointments and ask that you give us the courtesy of a call when you are unable to keep your appointment. This time will be reallocated to someone who is in need of treatment. We provide reminder calls the day before your appointment, as well as automated emails and texts.

How to cancel your appointment: To cancel your appointment, please call 831-475-1479 or email us at chanticleervet@gmail.com

Late Cancellations: A cancellation is considered to be late when the appointment is cancelled without 24-hour advance notice.

No Show Policy: Our "no-show” policy applies when a client misses an appointment without cancelling it or fails to give more than 24-hour notice. Failure to be present at the time of a scheduled appointment is documented. This includes late arrivals of 10 minutes or more from your scheduled appointment time.

We understand that everybody has “one of those days” where an appointment may need to be cancelled at the last minute. Please call our office to let us know that you will be unable to make your scheduled appointment time.

If a client has three consecutive “no-show” appointments or shows a pattern of missed/late appointments, they will be required to pre-pay for their next exam fee. The deposit will be forfeited if the appointment is missed or not cancelled with at least 24 hours’ notice prior to the appointment.

I understand

Payment Policies*

Payment Policy: We require full payment at the time that services are rendered. For your convenience, we accept Visa, MasterCard, Apple Pay, Discover, American Express, cash, and personal checks. We do not offer any in-house payment plans or loans. If you have any questions about payment, please discuss them with your client service representative prior to seeing the doctor.

I understand

Consent*

By signing below, I authorize Chanticleer Veterinary Hospital to examine my pet and I accept financial responsibility for all services performed.

We ask you to join us in this pledge…

At Chanticleer Veterinary Hospital we value transparency and vulnerability in order to cultivate a culture of respect, trust, and empathy. This leads to more open communication and collaboration, both within our team and with our clients. We place a strong emphasis on lifelong learning, the human-animal bond, and relationship-centred care which fuels our approach to both medicine and client interactions.

Our staff is committed to treating each other, clients, and patients in a way that reflects our team values, and we expect our clients to do the same. By signing this agreement, we pledge to hold each other accountable for upholding these values and to help us maintain our culture.

I agree to the Hospital Policies Above

Date

Owner's Name

Co-owner's Name & Contact #

Pet Information

Hospital Policies

Contact Us

Location

Contact

Hours

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