"*" indicates required fields Please call us before coming in. Filling out this registration form does NOT mean you are making an appointment.Name of legal owner* Spouse / Co-owner name AddressStreet Address* City* State / Province / Region* ZIP / Postal Code Cell Phone*Home PhoneOther PhoneAdditional Phone NumbersNumberMobile / Landline? Add RemovePlease click the (+) symbol to add more numbers.Email* Have you been to our hospital before?* Yes No Do you have pet insurance for this pet?YesNoWhat is the name of your pet insurance company?* Do we have your permission to share your pets medical records and/or other requested documents with your insurance company if they request them?*YesNoPet InformationPet #1*NameBreedAgeColorSexFixed (Y/N) Add RemovePlease click the (+) symbol to add another pet.**For exotic pets (i.e. other than dogs and cats)** I understand that Rockingham Emergency Veterinary Hospital does not have an exotic pet specialist on staff, and the doctors at REVH are not experts or specialists in exotic species. As an emergency hospital, REVH can typically provide only basic supportive care and stabilization for exotic patients. Depending on your pet's needs, you may be referred back to your primary care veterinarian or to an exotics specialist for further care or diagnostics.Primary Complaint* Do you have a primary care veterinarian?* Yes My pet does not have a primary care veterinarian Please list your primary care veterinary clinic* Any allergies to medications or vaccinations? Is your pet on any medications? How would you like to pay today?*Payment is due at the time services are rendered. We do not accept checks. Visa/Mastercard/Discover/American Express Debit Care Credit Cash AUTHORIZATION FOR USE OF PHOTOGRAPH OR LIKENESS*I permit and authorize Rockingham Emergency Veterinary Hospital, its employees, agents and personnel who are acting on behalf of the hospital to use my pet’s photograph and first name for purposes related to the business of the hospital, including publicity, marketing, and promotion of the hospital and its various websites Yes No Rockingham Emergency Veterinary Hospital is an ABUSE-FREE WORKPLACE. By initialing here, I understand that REVH has a ZERO TOLERANCE policy for profanity and verbal abuse. I further understand that any profane, abusive, or hostile behavior or language directed at any member of the REVH team will result in immediate removal from the hospital, and I will no longer be allowed to bring any of my pets to REVH in the future, for any reason.* I, the undersigned, certify that I am 18 years of age or older and I am the legal owner (or authorized agent of the owner) of the patient listed above. I agree to assume financial responsibility for all charges incurred and agree to pay such charges at the time of services rendered. I also understand that personal checks are not accepted. I am responsible for all interest and collection fees on any unpaid balance, as well as reasonable attorney fees and court costs associated with collection of unpaid balances. I acknowledge that the above information is true and accurate to the best of my knowledge.Signature*Date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
