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Welcome Text

Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together. Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight into providing optimal care for your pet(s). The required sections have a red * asterisk.

Appointment Date/Time

Your Name

Place of employment

Address

City

State

Zip

Primary Phone

Secondary Phone

Email

Co-Owner Name

Co-Owner Phone

How did you find out about our practice?

Previous Veterinarian/Vet Clinic

Pet's Name

Species

Breed

Color/Markings

Birthday/Approximate Age

Does Your Pet Have a Microchip?

Yes
No

Microchip Number

Sex

Spayed/Neutered

Is your pet currently on any medications?

Yes
No

Please list medications and dosages

Heartworm Prevention?

Flea/Tick Prevention?

Previous Medical/Behavioral History

(please check all that apply)

Please list allergies

Any Other Medical Conditions You Wish to Explain

Do you have another pet?

Yes
No

Pet's Name

Species

Breed

Color/Markings

Birthday/Approximate Age

Does Your Pet have a Microchip?

Yes
No

Microchip Number

Sex

Spayed/Neutered

Is your pet currently on any medications?

Yes
No

Please list medications and dosages

Heartworm Prevention?

Flea/Tick Prevention?

Previous Medical/Behavioral History

(please check all that apply)

Please list allergies

Any other medical conditions you wish to explain

Consent

White Rock Veterinary Hospital does not share your information with any other establishments or individuals. The information requested on this form is required to set up and maintain a file with White Rock Veterinary Hospital. For your convenience, we accept cash, personal checks, Visa, Master Card, and Discover.

Payment is expected at the time services are performed. When more extensive care is necessary, financial arrangements can be made with our hospital through Care Credit or Citi Health Card.

I also agree should it become necessary to forward my account for collection proceedings, in addition to the amount I owe, I will also be responsible for the fees associated with the costs of collections.

Agreement

I agree to the Privacy Policy.

Photo Release

Unless declined I understand that my pet's photo may be used on White Rock Veterinary Hospital's website and social media to help maintain, expand, and educate the public about our services.

Acknowledgment

I choose not to have my pet's picture shared.

Today's Date

Cancellation Fee Notice

*There will be a $25.00 cancellation fee for any missed appointments without 24 hours prior notice.*