harbor

New Client Registration Form


Owner’s Name: Spouse/Other:  
Date: Address:

City: State: Zip:
Home Phone # Cell Phone #
Employer Name: Work #
 Email for appointment reminders:
Driver’s License # (required) State of License
Name and phone number of the Person to contact in case of an EMERGENCY:
 
Does anyone in the household have a suppressed immune system?
Patient Information
Pet’s Name:
Sex:

Approx. Date of Birth or Age:
Species: Dog Cat Other:
Breed: Color:
List of medications this pet is currently on:
 
Reason for visit:
Previous Veterinarian(s) where past records can be obtained:
Social Media Permission: I allow Harbor Animal Hospital to take photographs/videos of my pet to post on Harbor Animal Hospital's social media pages. Accept 
I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment.
*All returned checks will be charged a $25.00 insufficient funds bank fee. Any account left unpaid will be sent to collections and charged an additional collection fee of 33 1/3%.

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Signature Certificate
Document name: New Client Registration Form
lock iconUnique Document ID: 9689f245f369a5f229fb2b364611c72f78c7e81f
Timestamp Audit
October 13, 2020 3:59 pm ESTNew Client Registration Form Uploaded by Harbor Animal Hospital - clientservices@harboranimalhospital.org IP 24.34.242.62