New Client & Patient Registration

We pledge to do our very best to care for your pet's health needs. In return we ask you to accept responsibility for charges incurred in treatment of your pet and accept that payment is due when services are rendered. Please feel free to ask for an estimate prior to services performed. If at anytime you are not satisfied with our service, please let us know. We are happy to answer any questions you may have.

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If you are here to fill out information for Dr. Montgomery's referral service,
please visit the Referral Page instead!

Client Section

Name

First Name

Last Name

Spouse (Other) Name

First Name

Last Name

What is Spouse (Other)'s relationship to you?

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

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Cell Phone

(###)

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Work Phone

(###)

###

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Spouse (Other) Phone Number

(###)

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####

How would you like us to contact you for appointments?

Phone Call

Text

Drivers License Number (For check writing.)

How did you hear about us? (Please list any names so we can thank them for their referral!)

Are you one of the following? (ID will be verified upon arrival)

(Choose One)

Patient 1

Pet 1 Name

Pet 1 Sex

Pet 1: Is your pet Neutered/Spayed?

Pet 1 Date of Birth

If you do not know your pet's birthday, you can give your closest guess.

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Pet 1 Breed

For unknown CAT breeds write: Domestic Short Hair, Domestic Medium Hair, or Domestic Long Hair.

Pet 1 Color

Pet 1: Is your pet microchipped?

Choose one of the following.

Pet 1 Microchip #:

Pet 1: Any allergies known?

Pet 1: Please list below.

Pet 1: Any diagnosed illness or injuries?

Pet 1: Please list below.

Pet 1: Any Previous Surgeries?

Other than Neuter/Spay.

Pet 1: Please list below.

Pet 1: Please list all the medications your pet is taking (including over the counter medications).

PATIENT 2

(If not applicable, skip to general information below)

Pet 2 Name

Pet 2 Sex

Pet 2: Is your pet Neutered/Spayed?

Pet 2 Date of Birth

If you do not know your pet's birthday, you can give your closest guess.

YYYY

Pet 2 Breed

For unknown CAT breeds write: Domestic Short Hair, Domestic Medium Hair, or Domestic Long Hair.

Pet 2 Color

Pet 2: Is your pet microchipped?

Choose one of the following.

Pet 2 Microchip #:

Pet 2: Any allergies known?

Pet 2: Please list below.

Pet 2: Any Previous Surgeries?

Other than Neuter/Spay.

Pet 2: Please list below.

Pet 2: Please list all the medications your pet is taking (including over the counter medications).

General Information

Has your pet been to a veterinary clinic or had vaccines before?

Please list where vaccines were given or your previous veterinary office and phone number if available for each pet. (If your pet or pets were listed under a different name, please let us know.)

Media Release Authorization

Pet owners and their pets are often photographed for use in Davis Animal Hospital promotional materials and publicity efforts. These photographs may be used in a publication, print ad, direct-mail piece, electronic media (e. g. video, CD-ROM, Internet/World-Wide Web)or other form of promotion. By selecting yes you release Davis Animal Hospital and all employees from liability for any violation of any personal or proprietary right in connection with such use.

Medical Inquiry & Release Authorization

I give permission for the doctors and staff of Davis Animal Hospital to release or inquire about necessary medical information and vaccination status concerning my pet from other animal care professionals such as other veterinary hospitals, animal control, boarding facilities, grooming facilities, rescue or shelter organizations or other related animal care professionals. Current vaccination status may also be obtained from us by the health department or landlord.

Treatment Authorization

I am the owner/authorized agent for the animal named above, and I am 18 years of age or older. I give permission for the doctors and staff of Davis Animal Hospital to examine and treat my pet as I have requested. I understand that medical therapy of any kind involves some risk to my pet, including but not limited to adverse drug reactions, and agree to hold the hospital and its employees harmless in the absence of negligence, in connection with these procedures. I acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained. In the event of an emergency I understand that life saving measures will be initiated while an attempt is made to contact me. If I cannot be contacted at the listed numbers, the doctors and staff are directed to make decisions deemed best for my pet. I understand that payment is due when services are rendered, and I agree to pay for those services rendered. I understand that interest will accrue on any balance outstanding over 30 days at 1.5% per month (18% annually) and a $5.00 handling fee will be assessed on each monthly statement. I agree to pay for these and any additional cost incurred by the hospital in the collection of any outstanding debt for services rendered.

I agree to the above.

E-Signature

Typing my initials confirms that the above information is accurate to the best of my knowledge.

Who do you have an appointment scheduled with?

NOTE: DR MONTGOMERY PATIENTS PLEASE VISIT THE REFERRAL PAGE INSTEAD.

Please choose the date of your appointment (If scheduled.)

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