Conestoga Animal Hospital Pet Records For existing clients only. Client & Pet Registration Thank you for choosing us to care for your pet(s). We are conducting a survey and updating our records. Please complete this form accurately so that we can better serve you and your pet(s). "*" indicates required fields Client Name* First Last Spouse Name First Last Email* Enter Email Confirm Email Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell Phone*Work PhoneSpouse PhonePreferred method of contact:* Home Cell Work Preferred Method of Contact for Annual Exam/Vaccine Reminders: Mail Email Select AllWould you be interested in receiving appointment reminders via email?* Yes No Pet InformationFirst Pet’s Name* First Pet is a:* Dog Cat Other Breed Color Sex/Altered Date of Birth Month Day Year Do you have an additional pet?* Yes No Second PetSecond Pet’s Name* Second Pet is a:* Dog Cat Other Breed Color Sex/Altered Date of Birth Month Day Year Do you have a third pet?* Yes No Third PetThird Pet’s Name* Third Pet is a:* Dog Cat Other Breed Color Sex/Altered Date of Birth Month Day Year Do you have a fourth pet?* Yes No Fourth PetFourth Pet’s Name* Fourth Pet is a:* Dog Cat Other Breed Color Sex/Altered Date of Birth Month Day Year Do you have a fifth pet?* Yes No Fifth PetFifth Pet’s Name* Fifth Pet is a:* Dog Cat Other Breed Color Sex/Altered Date of Birth Month Day Year Do you have a sixth pet?* Yes No Sixth PetSixth Pet’s Name* Sixth Pet is a:* Dog Cat Other Breed Color Sex/Altered Date of Birth Month Day Year AuthorizationBy checking "I agree", I, the CLIENT named above hereby Authorize the veterinarian to examine, prescribe for, and/or treat my pet(s) both listed above and unlisted. I understand that unforeseeable adverse reactions to treatments are a possibility and the veterinarian is not at fault. I assume full responsibility for all charges incurred for the care of this/these animal(s). I also understand that these charges will be paid at the time of service, unless prior arrangements have been made. Deliquent accounts are susceptible to late fees and/or submission to a collections agency. I understand and agree to pay all additional charges related to my deliquent account. We accept cash, checks, Visa, Mastercard, Discover, American Express and CareCredit. There will be a service charge (up to the maximum allowed by law) for any check returns. To prevent the spread of infectious diseases, all hospitalized and boarding patients must be current on all vaccines, and free of internal/external parasites. Rabies vaccines will be administered to all patients according to Pennsylvania state law. The signature below verifies that I am 18 years of age or older, that I understand and assume financial responsibility for all charges to my account, and that I will not hold Conestoga Animal Hospital, Inc or it’s staff liable.* I agree I, the CLIENT named above I grant permission to Conestoga Animal Hospital, Inc. to use photo’s, videos and/or information about my pet for the purpose of social media/website use.* I agree to use photo/video and first name of pet. No, I decline. Name First Last