New Client Registration

Client Information

Owner Name *

First

Last

Co-Owner Name

First

Last

Spouse Name

First

Last

Primary Phone *

Cell Phone *

Work Phone *

May we contact you at work? *

Yes
No

Spouse Work Phone

May we contact your spouse at work?

Yes
No

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Client's (Owner) Date of Birth *

Place of Employment and Position/Title *

Employment of Spouse and Position/Title *

How did you become aware of our hospital and pet hotel? *

If Personal Recommendation – Who may we thank?

Pet Information and Health History

Pet #1 Name *

Color/Markings *

Pet Species and Breed/Mix *

Date of Birth/Age *

Male/Female – Select One *

Male
Female
Male, neutered
Female, spayed

Have you ever taken your pet to a Veterinarian? *

Yes
No

Has your pet ever been vaccinated? *

Yes
No

Is your pet microchipped (answer yes or no)? If yes, list microchip number. *

Do you have pet insurance (answer yes or no)? If yes, list name *

Is your pet allergic to any vaccines or medications? If yes, please list *

Is your pet on any medications, including Heartworm Prevention or Flea Control? If yes, list all medications *

Has or does your pet have any serious illness or injury (answer yes or no)? If yes, list: *

Has your pet been under anesthesia for any reason besides a neuter or spay? If yes, please explain *

Who is your pet's current veterinarian? *

Pet #2 Name

Color/Markings

Pet Species and Breed/Mix

Date of Birth/Age

Male/Female – Select One

Male
Female
Male, neutered
Female, spayed

Have you ever taken your pet to a Veterinarian?

Yes
No

Has your pet ever been vaccinated?

Yes
No

Is your pet microchipped (answer yes or no)? If yes, list microchip number:

Do you have pet insurance (answer yes or no)? If yes, list name:

Is your pet allergic to any vaccines or medications? If yes, please list:

Is your pet on any medications, including Heartworm Prevention or Flea Control? If yes, list all medications:

Has or does your pet have any serious illness or injury (answer yes or no)? If yes, list:

Has your pet been under anesthesia for any reason besides a neuter or spay? If yes, please explain:

Who is your pet's current veterinarian?

For any additional pets please go to the additional pet form located under Client Center.

Owner Agreement and Consent

*All fees are due upon release of patient/guest. We accept all major credit cards (Visa, MasterCard, Discover, and American Express), Care Credit, cash and personal check ($30.00 fee for all returned checks). A deposit is required for major medical or surgical procedures.

*We require a Driver’s License number on all personal checks. We also require personal identification when paying by credit card. If you elect not to give us this information you may pay by cash.

*I acknowledge and accept full financial responsibility for all services rendered. I agree to pay any service charge or interest (18% per year) that will be assessed to any balance over 30 days past service date. In the event of default, I understand the balance due may be placed with a collection agency and I agree to pay the balance and the cost of collection fee. In the event of legal action, I agree to pay reasonable attorney fees and court costs.

*I understand that Petsburgh Pet Care is not responsible for any accidental illness or injury incurred by my pet(s) beyond the control of the staff while staying or visiting at Petsburgh Pet Care unless due to the gross negligence or intentional misconduct of Petsburgh Pet Care.

*By entering your email address in the above space, you give us permission to send reminders, promotions and other offers. You may unsubscribe at any time.

*Please sign below

Please select agree or disagree to the above paragraphs: *

I agree
I disagree

I grant permission to Petsburgh Pet Care to use my pet’s name, information, picture and/or video for use in Petsburgh Pet Care’s publications such as brochures, newsletters, display boards, website, or other electronic forms of media.

Permission to use pet's photo and/or video: *

I agree
I disagree

Why is your pet coming to Petsburgh? *

Please remember to send vaccination records/medical records. You can fax them 765-742-1730 or email ([email protected]) them to us.

Enter BOARDING dates (for boarding only):

I understand for medical services there is a required 65.00$ deposit, and for grooming there is a $55 deposit to be paid at the time of scheduling: subject to wave/return if canceled 24 hours in advance.

You do not have an appointment scheduled until we call you back and set this up and take a deposit. Thank you.

Please Check those that Apply *

Yes – I am scheduling a medical appointment
No – I am not scheduling a medical appointment.
Yes – I am scheduling a grooming appointment

Signature of Owner or Authorized Agent: *

Date: *

Client Information

Pet Information and Health History

For any additional pets please go to the additional pet form located under Client Center.

Owner Agreement and Consent

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