NEW CLIENT REGISTRATION

By completing this online form, I authorize the examination of my pet, the performance of requested procedures and/or any related procedures deemed necessary by the veterinarian. I understand and acknowledge that no guarantee has been made regarding the results of the intended or any other unexpected but necessary treatment.

I understand that I assume financial responsibility for all services rendered and know and agree that payment is due on the date of services.

Drop off appointments – We will notify you when your pet is ready.

"*" indicates required fields

Today's Date*

Name*

Co-Owner's Name

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Primary Phone*

Email Address*

Enter Email Confirm Email

Co-Owner Email

Co-Owner Cell

Patient Information

For each patient please list their: Name, Species, Breed, DoB, Color, Sex, and whether the animal is spayed or neutered

Pet Name*

Species*

Breed*

Color & Markings*

Birthday/Age*

Sex*

Is your pet spayed/neutered?*

Is your pet microchipped?*

Should your pet be muzzled?*

Do you have another pet?*

Second Pet Name

Second Pet Species

Second Pet Breed

Second Pet Color & Markings

Second Pet Birthday/Age

Second Pet Sex

Is your second pet spayed/neutered?

Is your second pet microchipped?

Should your second pet be muzzled?

Communication Consent

We may need to contact you about your pet's health, please consent by selecting the best methods(s) of communication:*

Would you like to receive text message updates regarding overnight stays, surgeries, and other medical information related to you pet? If yes, please provide the best phone number to text you.

Permission to share your records with Other Hospitals/Emergency/Specialty?*

Permission to share your records with Groomers/Daycare?*

Permission to share your records with Pet Insurance?*

Where should we call for previous vaccination and medical history?*

Any chronic health problems?*

Any allergies to vaccinations or medications?*

Is your pet on any special diets or medications?*

Media Consent

I grant to Bissonnet Southampton Veterinary Clinic, its representatives and employees the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically. I agree that Bissonnet Southampton Veterinary Clinic may use such photographs of me and/or my pet with or without my name and for any lawful purpose, including but not limited to publicity, illustration, advertising and web content.*

Authorization

I, the undersigned, do hereby certify that I am the owner, or assuming responsibility, financial or otherwise, for the animal being presented to Bissonnet Veterinary Hospital for the treatment of care. I hereby consent and authorize Bissonnet Veterinary Hospital to receive, prescribe for or treat, as indicated, this animal presented. It is thoroughly understood that I assume all risks. I agree, if appropriate, to pick up this animal at the designated date and time agreed to by myself and Bissonnet Veterinary Hospital. If in the event that the animal is not picked up, there will be a notice of 10-days to come claim the animal or it will be considered abandoned. The animal will be held in the manner that is considered to be most appropriate for the animal and the hospital. It is understood that I am not released from costs associated with the care of the pet. We do not bill and all fees are due when services are rendered. Deposits are required for all hospitalized patients. Our Hospital only accepts cash, personal checks (driver’s license required), Visa/MasterCard, American Express, Discover Card, Scratchpay, and Care Credit. I understand that if I do not pay my balance in full, that I am responsible for all statement fees, finance charges, and attorney/collection fees.*

How did you hear about us?*

Please specify

Promotion Code

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