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

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



    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/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.