Dr.
Mr.
Mrs.
Miss
Ms.
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Contact Telephone Numbers |
Home Number (with area code) (required)
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Work Number
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Cell Number
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Employment Information |
Occupation
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Employer
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E-Mail Address (required to access pet records on-line) :
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Pet Information |
Pet Name
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Type of Pet
Dog
Cat
Bird
Rabbit
Guinea Pig
Other
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Breed
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Color
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Gender
Male
Female
Unknown
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Spayed/Neutered?
Yes
No
Unknown
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Date of Birth:
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Are This Pet's Vaccines Current
Yes
No
Not Sure
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Do You Have This Pet's Medical Records
Yes
No
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Second Pet (or scroll to 'other information' below) |
Pet Name
|
Type of Pet
Dog
Cat
Bird
Rabbit
Guinea Pig
Other
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Breed
|
Color
|
Gender
Male
Female
Unknown
|
Spayed/Neutered?
Yes
No
Unknown
|
Date of Birth
|
Are This Pet's Vaccines Current
Yes
No
Not Sure
|
Do You Have This Pet's Medical Records
Yes
No
|
Third Pet (or scroll to 'other information' below) |
Pet Name
|
Type of Pet
Dog
Cat
Bird
Rabbit
Guinea Pig
Other
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Breed
|
Color
|
Gender
Male
Female
Unknown
|
Spayed/Neutered?
Yes
No
Unknown
|
Date of Birth
|
Are This Pet's Vaccines Current
Yes
No
Not Sure
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Do You Have This Pet's Medical Records
Yes
No
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Other Information |
Are There Medical Records For Your Pet (at another veterinary practice)
Yes
No
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Name of Former Veterinary Practice
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Phone (if known)
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May We Request a Transfer of Records
Yes
No
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How Did You Learn About Us? (check all that apply)
Phone Book
Internet Search/Website
Location
SPCA
Breeder
I am a former client
Pet Store
Dr. Referral
Friend or Relative
Other
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If Pet Store, Dr. Referral, Friend or Relative, or Other Please provide name
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I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Georgetown Animal Clinic, P.C. and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Georgetown Animal Clinic, P.C. collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges. |
I have read this statement and (required)
I agree
I do not agree
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WE ACCEPT THE FOLLOWING: CASH, CHECK, MASTER CARD, VISA, AMERICAN EXPRESS, DISCOVER.
WE CAN ARRANGE FOR CARE CREDIT, ASK OUR RECEPTIONIST FOR DETAILS. |
If there is anything else you would like to tell us, please enter your comments here
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