New Client Registration

SPOUSE /CO-OWNER:

IF YOU ARE NOT PET’S OWNER (i.e., pet sitter, friend, temporary guardian, other):

OTHER EMERGENCY CONTACT  (if no emergency contact available, please write “self” below)

PLEASE TELL US REASONS YOU’VE CHOSEN OUR HOSPITAL …  (Please check all that apply)

YOUR PETS 

PET #1

PET#2

PET#3

PET HISTORY: 

PAYMENT

Payment is due at time of service.  We gladly accept MC, Visa, Discover, Scratch pay, Care Credit, cash.

TERMS AGREEMENT & RECORDS RELEASE AUTHORIZATION

By typing my full name below, I accept the hospital policies and payment terms outlined on this form. I also authorize Animal Hospital of Mt. Pocono to request and receive my pet’s patient records from other animal facilities as needed, and to release my pet’s patient information from Animal Hospital of Mt. Pocono when requested by other animal facilities, for the health care and treatment of my pet.