New Client Registration Form

Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.

Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.

Owner's Name
Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
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?*
- Clinic Location
- Personal Referral
- Internet Search / Website
- Yellow Pages
- SPCA/ Rescue
- Newspaper / Print Media
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)
Date Format: MM slash DD slash YYYY
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
Date
Date Format: MM slash DD slash YYYY

New Client Registration Form

Owner's Name

Co-owner's Name & Contact #

Pet Information

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