New Patient Registration - St. Georges Veterinary Hospital

Name *

First

Last

Spouse's Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Work Phone

Social Security Number (Required for owner identification purposes) *

Driver's License Number (Required for owner identification purposes) *

Where did you learn of our hospital?

Have pets here
Other

Please explain:

Current Place of Employment

If you would like to receive e-mail reminders for your pet, please enter your e-mail address:

Pet's Name *

Date of Birth *

Breed *

Dog
Cat

Color *

Sex *

Male
Female
Neutered Male
Neutered Female

Where was pet obtained? *

Reason for Visit *

Any known allergies? *

Most Recent Date of Rabies Vaccine *

Most Recent Date of Distemper Vaccine *

Most Recent Date of Heartworm Test *

Most Recent Date of Bordetella Vaccine *

Most Recent Date of Rabies Vaccine *

Most Recent Date of FVRCP Vaccine *

Feline AIDS/Feline Leukemia Test Performed? *

Yes
No

Results: *

I hereby authorize the veterinarians and staff of St. Georges Veterinary Hospital to examine, prescribe for, and/or treat the above-described pet. I assume responsibility for any and all charges incurred in the care of this animal. I ALSO UNDERSTAND THAT THESE CHARGES WILL BE PAID AT THE TIME OF SERVICES RENDERED, OR RELEASE, AND THAT A DEPOSIT IS REQUIRED FOR SURGICAL TREATMENT OR HOSPITALIZATION. A billing fee and finance charge will be applied to all accounts unpaid after 30 days. The finance charge is computed by a periodic rate of 1.50% per month, which is the annual percentage rate of 18.00%, with a minimum charge of $1.00.

Digital Signature of Owner *

Date *

New Client Registration

Fill out the new client registration form online!