Client Medical Registration Form - Poultney Veterinary Hospital

Registration Form for New Clients

Welcome to our medical family!
Thank you for giving us the opportunity to care for your furry family members.

So that we may become better acquainted, please complete the form below.

We charge a $35 patient set up fee. It will be collected by phone prior to your first appointment,

Full Name *

Spouse/Co-Owner's Full Name

Phone *

Spouse/Co-Owner's Phone

Additional Phone (work)

Email Address

Street Address *

City

State

ZIP

Place of Employment

Best Time to Reach You

Names of Additional Person to be Listed on Account (family, roommates, etc)

How Did You Hear About Us? (Personal Referral, Facebook, Yelp, Google Search, Drive-By, etc.) If a personal referral, please list their name so we can thank them!

Treatment Authorization *

I hereby authorize Poultney Veterinary Hospital to perform medical and initial diagnostic/surgical procedures on this animal as required
for diagnosis and treatment. I understand that I can terminate treatment at any time by contacting the doctors and assistants.

Information/Photo Release

PVH and its staff are leaders and teachers in the veterinary medicine field, thus case information and/or photos may be used in teaching,
forms of continuing education, PVH’s website and social media, veterinary literature, and the like. I authorize the release of case/patient information for such purposes.

Release of Medical Records

In the event that I sell/give this animal to another owner, I authorize release of medical information to the new owner.

Financial Policy - Please indicate preferred form of payment.Payment is due as services are rendered. For hospitalized/admitted cases, a deposit is required in advance. The balance is due upon discharge from the hospital. Payments can be made by cash, personal check and accepted credit cards, including Care Credit.

I have read and accept the preceding obligations. Please enter your name and the date to indicate agreement. *

Please do not fill in this field.