New Client Registration

First Name *

Last Name *

Home #

Cell # (if no cell #, type your home # under cell #) *

Home Address *

City *

State *

Zip *

Primary Email Address *

Employer

Work #

SPOUSE /CO-OWNER:

First Name

Last Name

Cell/Home Phone #

Email *

Employer

Work #

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

Your Name

Relationship to Owner

Your Address

Phone(s)

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

Name/Phone *

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

REFERRED by

Internet SearchPhone Book (Verizon or Yellow bookPromotional mailingSign

Other

YOUR PETS

PET #1

Pet’s Name *

Species/Breed *

Pet’s date of birth *

Sex *

Spayed / Neutered *

Color *

PET#2

Pet’s Name

Species/Breed

Pet’s date of birth

Sex

Spayed / Neutered

Color

PET#3

Pet’s Name

Species/Breed

Pet’s date of birth

Sex

Spayed / Neutered

Color

PET HISTORY:

Regarding your pet, What is the main concern for your upcoming visit?

Current or past medical conditions?

Current medications?

Are your pet(s) currently on heartworm prevention medication? *YesNo

Are your pet(s) currently on Flea and tick prevention medication?YesNo

Have your pet(s) been microchipped (for Lost Pet Identification)? *YesNo

OTHER HOSPITALS where my pet(s) have been treated:

PET PHOTO PERMISSION REQUEST *

May we include your pet’s photo, first name, and stories in social media, Animal Hospital of Mt. Pocono website, hospital advertising, or other materials? Pet photos are for in-Hospital use only and are never shared or sold. Please check one box below:

YES, I authorize Animal Hospital of Mt. Pocono to use photos of my pet(s) for the purposes described above.NO, I do not want the Animal Hospital of Mt. Pocono to use photos of my pet(s) for the purposes described above.

PAYMENT

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

My method of payment will be

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.

NAME of responsible agent for pet: *

Date *

Call Us! Button

Header Logo

Request an Appointment Button