New Client Registration Form – All Creatures Veterinary Clinic

Today's Date*

Name*

First Last

Home Phone*

Work Phone

Cell Phone*

Email*

Spouse's Name

First Last

Spouse's Work Phone

Spouse's Cell Phone

Address*

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

How did you hear about us?

Drove by
Google
Facebook
Yelp
Referral
Other

Pet Information

Species:*

Dog
Cat

Name:

Breed:

Age/Birthdate:

Color:

Sex:

ID # (tattoo, microchip, etc.):

Please give approximate Dates of Last Rabies Vaccine:

Please give approximate Dates of Last Distemper/ Parvo (Canine):

Please give approximate Dates of Last Kennel Cough (Canine):

Please give approximate Dates of Last Heartworm Test:

Please give approximate Dates of Last Feline Leukemia:

Please give approximate Dates of Last Distemper/Upper Respiratory (Feline):

Please give approximate Dates of Last Lyme (Canine):

Please give approximate Dates of Last Fecal:

Please list your previous veterinary hospital, if applicable:

Has your pet had any reaction to vaccinations or medications?

Is your pet on any current medications?

What type of food do you feed?

Any previous illnesses or injuries?

Is your pet on heartworm preventative?

Yes
No

If yes, list product:

Is your pet on flea/tick preventative?

Yes
No

If yes, list product:

ACVC Payment Policy

Payment is required at the time services are rendered. We make every effort to make sure all fees are fair and reasonable and encourage you to discuss charges before services are rendered. For your convenience, we accept Visa, MasterCard, Discover, American Express, and cash. We only offer payment plans through Care Credit. Please visit the website www.carecredit.com to find a plan that suits your needs. For further questions please ask one of our customer service representatives. You may also apply for Care Credit by using our PetDesk app, downloadable from the app store on your mobile device. A link is located on the provider front page of the app.
Cancellation Policy: In accordance with All Creatures Veterinary Clinic cancellation policy I understand failure to show up for my scheduled appointment or give less than 24-hour notice to cancel, will result in a non-refundable charge of $60.

Consent*

I have read and accept the financial policy.

Date*

Social Media Consent*

We want your pet to be Social Media Famous! Here at All Creatures Veterinary Clinic we sometimes publish cute photos or case studies for educational purposes. Do we have your permission to do so?

Yes, I will allow ACVC to use my pet’s image/information on their social media page.
No, I will not allow ACVC to use my pet’s image beyond their private medical history.

Other Services Available*

In addition to the friendly phone customer service you have grown to love, we are offering another quick and easy mode of communication about your pet’s health between our hospital and you. This is available through our free client app, PetDesk. Would you like to learn how to get started?

Yes
No
Would like more information

How likely are you to shop our online pharmacy and store?*

Very Likely
Not Likely
Maybe

New Client/Patient Registration

Pet Information

ACVC Payment Policy