Client & Patient Registration Form "*" 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 Address* Street Address Address Line 2 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 Pet InformationPet #1*NameBreedAgeColorSexFixed (Y/N) Add RemovePlease click the (+) symbol to add another pet.Primary Complaint* Do you have a primary care veterinarian?* Yes No Who is your pet's primary veterinary hospital?* 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 I understand that I will need to stay on the grounds of Rockingham Emergency Veterinary Hospital throughout my pet’s entire visit. I also understand that failure to do so will result in a $63.00 hospitalization charge* I Understand 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 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 EmailThis field is for validation purposes and should be left unchanged.
