New Pet Client Registration in Maple Ridge

UNIT-112, 11865 227 STREET, MAPLE RIDGE, BC V2X6H8.
haneyanimalhosp@gmail.com
+1 (604) 476-2525

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Home
About
- Our Team
Services
Pet Resources
Forms
- Book an Appointment
- New Client Registration
Contact Us

Home
About
- Our Team
Services
Pet Resources
Forms
- Book an Appointment
- New Client Registration
Contact Us

Home
About
- Our Team
Services
Pet Resources
Forms
- Book an Appointment
- New Client Registration
Contact Us

+1 (604) 476-2525

Home
About
- Our Team
Services
Pet Resources
Forms
- Book an Appointment
- New Client Registration
Contact Us

Home
About
- Our Team
Services
Pet Resources
Forms
- Book an Appointment
- New Client Registration
Contact Us

New Client Registration

Owner's Name:

Co-Owner/Spouse/Relative's Name:

Address:

City:

Postal Code:

Home Phone:

Cell Phone:

Co-owner phone

Email:

Previous Veterinary Hospital

Does your pet have any allergies known to you? If so, please state

Do you have insurance?

Insurance Company

Policy/ Customer #

#1 Pet's Name

Species

Breed

Colour

Sex

Female Male

Spay OR Neuter

Yes No

Date Of Birth

Vaccines up to date?

Yes No

General health ?

#2 Pet's Name

Species

Cat Dog Other

Breed

Colour

Sex

Female Male

Spay OR Neuter

Yes No

Date Of Birth

Vaccines up to date?

Yes No

General health ?

#3 Pet's Name

Species

Cat Dog Other

Breed

Colour

Sex

Female Male

Spay OR Neuter

Yes No

Date Of Birth

Vaccines up to date?

Yes No

General health ?

I hereby acknowledge and agree to the terms and conditions set forth. By signing below, I confirm my acceptance and understanding of these terms.
A DEPOSIT MAY BE REQUIRED, AND FINAL BILLS ARE UPON RELEASE OF THE PATIENT. NO BILLING OR PAYMENTS PLANS.

Date

Signature Of Owner

Owner's Name:

Co-Owner Name:

Address:

City:

Postal Code:

Home Phone:

Cell Phone:

Co-owner phone

Email:

Previous Veterinary Hospital

Do you have pet insurance?

Insurance Company

Policy/ Customer #

#1 Pet's Name

Species

Breed

Sex

Female Male

Are they Spayed or Neutered?

Yes No

Date Of Birth

Are their vaccines up to date?

Yes No

Does your pet have any known health conditions or allergies?

#2 Pet's Name

Species

Cat Dog Other

Breed

Sex

Female Male

Are they Spayed or Neutered?

Yes No

Date Of Birth

Are their vaccines up to date?

Yes No

Does your pet have any known health conditions or allergies?

#3 Pet's Name

Species

Cat Dog Other

Breed

Sex

Female Male

Are they Spayed or Neutered?

Yes No

Date Of Birth

Are their vaccines up to date?

Yes No

Does your pet have any known health conditions or allergies?

Date

I hereby acknowledge and agree to the terms and conditions set forth. By signing below, I confirm my acceptance and understanding of these terms.

Financial Agreement and Authorization of Treatment: I authorize the above-named pet(s) and agree, irrevocably, that in the consideration of the services to be rendered, I hereby obligate myself to pay the account in accordance with the regular rates and terms of the provider.

As required by law, you are hereby notified that a negative credit report reflecting your credit may be submitted to a credit reporting agency if you fail to fulfill the terms of your credit obligations to our establishment. Should the account be referred to an attorney or collection agency for collection, the undersigned agrees to pay actual attorney's fees and collection expenses.

A DEPOSIT MAY BE REQUIRED, AND FINAL BILLS ARE UPON RELEASE OF THE PATIENT. NO BILLING OR PAYMENT PLANS.

I agree to receive text messages from Haney Animal Hospital about my request/appointment. Message & data rates may apply. Message frequency varies. Reply STOP to opt out. Reply HELP for help. View Privacy Policy.

By clicking Submit, you consent to receive SMS messages from Haney Animal Hospital related to your request/appointment. Message & data rates may apply. Message frequency varies. Reply STOP to opt out, HELP for help. Privacy Policy.

Signature Of Owner