New Client Registration Name Mr.Mrs.MissMs. Prefix First Last Address Street Address Address Line 2 City State Zip Code Email Primary PhoneWork PhoneHow did you hear about us? Sign Recommendation Internet Search Who recommended you? Thank you for choosing Cornwallis Road Animal Hospital! Our primary mission is to provide compassionate care, affordable rates, and superior comprehensive veterinary care with a family approach. We diligently strive to ensure that the cost of quality veterinary care is as economical and manageable for our clients as possible by offering multiple payment options.We offer multiple payment options in the form of: Cash, Check, Visa, MasterCard, Discover, American Express, and Care Credit.**All returned checks will be charged an additional $35.00.**Any necessary treatments and/or hospitalized care will be provided an estimate.**Cornwallis Road Animal Hospital requires payment in FULL at the time of check out.**By signing below, you acknowledge and fully understand the Cornwallis Road Animal Hospital financial policy and agree the Cornwallis Road Animal Hospital terms of payment.Electronic Signature* Date* MM slash DD slash YYYY Photo ConsentI hereby grant Cornwallis Road Animal Hospital permission to take photographs of my pet(s), and to publish those photographs for any lawful purpose, including but not limited to their website, social media accounts, and promotional materials either digital or in print, in perpetuity. I understand that Cornwallis Road Animal Hospital will not use my name or my pet's name.By electronically signing this form I authorize Cornwallis Road Animal Hospital to edit and share the photograph(s) mentioned above. I also waive any rights of privacy or compensation associated with the use of my pet(s) image(s) for the personal or commercial purposes outlined above.Electronic Signature Date MM slash DD slash YYYY Decline Pet Registration1st PET INFORMATIONPet Name Species Dog Cat Reptile Exotic Breed Color Date of Birth MM slash DD slash YYYY If unknown, approximate age: Sex Male Female Spayed/Neutered? Yes No Is your pet up to date on vaccines? Yes No Please list prior illnesses, surgeries, or allergies:Is your pet currently on any medications? Yes No Names and dosage:2nd PET INFORMATIONPet Name Species Dog Cat Reptile Exotic Breed Color Date of Birth MM slash DD slash YYYY If unknown, approximate age: Sex Male Female Spayed/Neutered? Yes No Is your pet up to date on vaccines? Yes No Please list prior illnesses, surgeries, or allergies:Is your pet currently on any medications? Yes No Names and dosage:
