New Client Check In

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 CellHomeWork

Cell Phone

Phone Type CellHomeWork

May we text you (reminders/prescriptions are ready, ect.)?

YesNo

Work Phone

Phone Type CellHomeWork

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 CellHomeWork

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/relativeyellow pagescivic group or community eventnewspaper adradio adnew resident programdirect mail or couponinternet adpet store or humane societysign,location,drove byour 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 AAHAExtended convenient hoursSunday hours for pickup and admitting (pet accommodations only)Overnight pet care M-F for hospitalized and healthy petsConvenient LocationPick Up and Delivery OptionsWe do housecallsReferral/Reputation in the communityLodging Facilities for dogs, cats (separate!), exotic petsPerson who answered the phone was friendly/competentLaser Surgery availablePain 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)

CanineFelineAvianExoticOther

Breed: (required)

Sex: (required)

MaleFemale

Neutered/Spayed

NeuteredSpayed

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?

YesNo

Name of Former Veterinary Practice

May we request a transfer of records?

YesNo

Would you like us to call you for your appointment

YesNo

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)

YesNo

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 $6 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 AgreeI Disagree

Check to confirm submission.