Home
About
Our Team
Services
Pet Care Services
Anesthesia & Patient Monitoring
Urgent Care
Medical Services
Nutritional Counseling
Surgical Services
Diagnostics
Wellness Programs
Dental Services
End Of Life Care
Additional Services
Pet Resources
Pet Insurance
Pet Food Alerts
Product Alerts
ASPCA Pet Poison Helpline
Vancouver Dog Licence
Pet Travel
Forms
Book an Appointment
New Client Registration
Careers
Contact
Home
About
Our Team
Services
Pet Care Services
Anesthesia & Patient Monitoring
Urgent Care
Medical Services
Nutritional Counseling
Surgical Services
Diagnostics
Wellness Programs
Dental Services
End Of Life Care
Additional Services
Pet Resources
Pet Insurance
Pet Food Alerts
Product Alerts
ASPCA Pet Poison Helpline
Vancouver Dog Licence
Pet Travel
Forms
Book an Appointment
New Client Registration
Careers
Contact
+1 (604) 416-4114
Register Now
Owner & Patient Information
Contact Us
Owner's Name:
Co-Owner Name:
Address:
City:
Postal Code:
Home Phone:
Cell Phone:
Co-owner phone
Email:
Previous Veterinary Hospital
Do you have pet insurance?
Yes
No
Insurance Company
Policy/ Customer #
#1 Pet's Name
Species
Cat
Dog
Other
Breed
Sex
Female
Male
Are they Spayed or Neutered?
Yes
No
Date Of Birth
Are their vaccines up to date?
Yes
No
Does your pet have any known health conditions or allergies?
#2 Pet's Name
Species
Cat
Dog
Other
Breed
Sex
Female
Male
Are they Spayed or Neutered?
Yes
No
Date Of Birth
Are their vaccines up to date?
Yes
No
Does your pet have any known health conditions or allergies?
#3 Pet's Name
Species
Cat
Dog
Other
Breed
Sex
Female
Male
Are they Spayed or Neutered?
Yes
No
Date Of Birth
Are their vaccines up to date?
Yes
No
Does your pet have any known health conditions or allergies?
Date
I hereby acknowledge and agree to the terms and conditions set forth. By signing below, I confirm my acceptance and understanding of these terms.
Financial Agreement and Authorization of Treatment: I authorize the above-named pet(s) and agree, irrevocably, that in the consideration of the services to be rendered, I hereby obligate myself to pay the account in accordance with the regular rates and terms of the provider.
As required by law, you are hereby notified that a negative credit report reflecting your credit may be submitted to a credit reporting agency if you fail to fulfill the terms of your credit obligations to our establishment. Should the account be referred to an attorney or collection agency for collection, the undersigned agrees to pay actual attorney's fees and collection expenses.
A DEPOSIT MAY BE REQUIRED, AND FINAL BILLS ARE UPON RELEASE OF THE PATIENT. NO BILLING OR PAYMENT PLANS.
By clicking SUBMIT you consent to receiving SMS messages from Homer Animal Hospital. Messages and Data rates may apply. Message frequency will vary. Reply Stop to Opt-out of messaging. Reply Help for Customer Care Contact Information. I have read and acknowledged the
Privacy Policy.
Signature Of Owner
Submit
