New Patient Registration Form – Veterinarians Cedar Rapids

Owner's Name

Name*

First Last

Address*

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

Day-Time Phone*

Evening Phone

Mobile Phone

Email*

(*used for appointment confirmations)

Enter Email Confirm Email

Co-owner's Name & Contact #

Name

First Last

Phone

Why did you choose us? (Please be specific)*

If Other, please specify:

If Personal Referral, is there someone we can thank for this referral?

Please use this area to give us any other relevant information about yourself or your family

Pet Information

Pet's Name*

Species*

or if other species

Breed (if known)

Color

Date of Birth (if known)

Sex

Previous Veterinary Practice (if any)

Previous Veterinarian (if any)

Date of last vaccines (if known)

What vaccines were given at this time

Is your pet on any medication or supplement?

Yes
No

If Yes, please list the medication or supplement

What food does your pet eat?

Does your pet have allergies or drug reactions?

Yes
No

If Yes, please list the allergies and reactions

Are there any current or past medical conditions of which we should be aware?

Yes
No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Please use the following box to give us any other relevant information about your pet

If you have already scheduled an appointment. Please list the date and time below.

Authorization

Please review the following items and select your preferred options. One selection must be made for each item for your registration to be accepted.

PHOTO CONSENT*

We love social media! Do we have your permission to share your pet(s)' image and story on social media, our website & other forms of related media? Your name and personal information will never be shared. Simply click below to authorize this.

Yes. I authorize Petersen Pet Hospital to share my pet's photo and story.
No. I do not authorize this.

TREATMENT CONSENT*

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet(s).

Yes. I authorize the above.
No. I do not authorize this.

PAYMENT CONSENT*

I assume responsibility for all charges incurred in the care of this animal. I understand that payment is always due IN FULL at the time of service. I recognize that financial concerns should be discussed PRIOR to exam & treatment. Our staff is happy to provide estimates. *WE DO NOT ACCEPT PERSONAL CHECKS OR AMERICAN EXPRESS. Please mark your method of payment below:

Name*

I understand that typing my first and last name in these boxes constitutes a legal signature confirming that I acknowledge and agree to the terms above.

First Last

Date*

Client Policies and Procedures

General Policies

• Clients are required to communicate with team members and other clients in a kind and respectful manner while at the hospital.
• It is required that a Veterinarian/Patient/Client (VPC) relationship exists prior to prescribing medications and providing a diagnosis/treatment(s). To establish and maintain a VPC relationship, we require that the patient be examined at least once yearly. The VPC relationship can be terminated at any time by either Petersen Pet Hospital or the client.

Financial Policies

• Payment in full is required at the time of services rendered.
• We accept Cash, Visa, Mastercard, Discover, American Express, and Care Credit.
• It is the client’s responsibility to request an estimate prior to services rendered.
• Unpaid balances will incur an account receivable finance charge and monthly statement fee.

Returns/Gift Certificates

• All gift certificates and referral cards must be presented at time of check-out.
• All discounts and promotions are only honored if services and products are paid in full.
• Prescription medications are non-returnable, and their sales are final.
• Any non-prescription items that are returned will be credited to the client’s account if returned within 14 days of purchasing.
• No cash refunds will be issued.

Safety of our Team Members, Clients and Patients

We strive to always keep you and your pet safe while at Petersen Pet Hospital. In doing so, please follow these rules:
• All dogs are required to be on a leash and firmly secured by their owners.
• Please avoid your pets from coming into contact with other pets in the hospital.
• All cats are required to be in a carrier or on a leash.
•Team members are required to restrain all patients during examination and treatments for your safety and ours.
• Clients are responsible for the behavior of their pets. Please inform our team members if your pet has a history of aggression and/or severe anxiety.

Name*

I have read and fully understand the policy and procedures regarding being a client of Petersen Pet Hospital. I understand that typing my first and last name in these boxes constitutes a legal signature confirming that I acknowledge and agree to the terms above.

First Last

Date*