New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.





New Client



First Name (required)

Last Name (required)



Spouse or Partner



First Name

Last Name

Children’s Names/Ages



Address (required)



Street Address (required)

City (required)

State / Province (required)

Zip / Postal Code (required)

Your Email (required)



Home Phone (required)



Phone Type



Cell Phone



Phone Type



Work Phone



Phone Type

Place of Employment

May we contact you at work?

Best time/phone # to call regarding your pet’s care:



Spouse/Partner Work Phone



Phone Type

Spouse/Partner Place of Emloyment

May we conact your spouse/partner at work?



Emergency Contact



First Name

Last Name

Emergency Contact Phone #:


How did you first hear about us? (required)
 Personal referral-friend/relative yellow pages civic group or community event newspaper ad radio ad new resident program direct mail or coupon internet ad pet store or humane society sign,location,drove by our website (www.companionsweb.com) other

If you first heard of us from a personal referral please let us know who to send a Thank You to!

Why did you decide to come here? (required)
 AAHA Accreditation! Ask us if you don't know about AAHA Extended convenient hours Sunday hours for pickup and admitting (pet accommodations only) Overnight pet care M-F for hospitalized and healthy pets Convenient Location Pick Up and Delivery Options We do housecalls Referral/Reputation in the community Lodging Facilities for dogs, cats (separate!), exotic pets Person who answered the phone was friendly/competent Laser Surgery available Pain Management Services-Therapy laser, massage… Veterinary Care for Exotics (birds,reptiles,rodents etc)

How do you view your pet(s) in terms of overall health concerns/issues?
 As a family member (I am concerned about all health issues and recommendations) As a pet (only concerned with basic health care such as exam and vaccinations)

Pet’s Name (required)

Date of Birth

Type of Pet (required)
 Canine Feline Avian Exotic Other

Breed: (required)

Sex: (required)
 Male Female

Neutered/Spayed
 Neutered Spayed

Pet’s color/markings (required)

Date of pet’s last examination

Please list all other pets below. Please include sex, if they are altered, breed and age.

Medical records at another veterinary Practice?
 Yes No

Name of Former Veterinary Practice

May we request a transfer of records?
 Yes No

Would you like us to call you for your appointment
 Yes No

Reasons or conditions that prompted your visit?

Special requests or conditions?

May we use your pet(s) picture(s) on our website and other materials (bulletin boards etc)? (required)
 Yes No

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Companions Animal Hospital and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly service charge of 2% and a $5 handling fee. Any balance that I leave unpaid will be forwarded to Companions Animal Hospital’s collection agency, and will incur a $35 collection fee for which I am liable, in addition to monthly finance charges.

I have read this statement and (required)
 I Agree I Disagree

 
 

Check to confirm submission.

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