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Patient Registration and Consent Form

Name(Required)

First

Last

Co-owner

First

Last

Address

Street Address

Address Line 2

City

State

ZIP Code

Home Phone

Cell Phone

Employer

Phone

OK to call?

Yes

Employer

Phone

OK to call?

Yes

Email(Required)

Permission for email reminders

Yes

No

List your current pets

Have you had pets treated here before?

Previous Veterinarian/Clinic

How did you FIRST learn of CVAH? (Please specify if appropriate)

Referred by client

Referred by shelter or rescue

Drove by hospital on Tullar Rd.

Found during online search

Noticed on Facebook

If referred by client (name)

If referred by shelter or rescue (name)

ACKNOWLEDGEMENT AND AUTHORITY: I, the undersigned, being over 18 years old, agree to pay for
authorized treatment, services and products deemed necessary and/or desirable for the care of my pet(s)
including, but not restricted to medications, conduction of laboratory work, radiographs, performance of
operations and/or other studies that may be utilized by a Doctor of Veterinary Medicine or a qualified CVAH
staff member. I accept full responsibility for the payment of services rendered. I understand that all fees are
to be paid for at the time that services are rendered. I acknowledge that my signature on this form represents
an agreement to comply with the previously stated policies of Country View Animal Hospital. I also authorize
CVAH to inquire and obtain my pets’ previous records from other practices.

Signature(Required)

Date(Required)

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Patient Registration and Consent Form

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920-722-1518

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920-722-1518