Client Name *

First

Last

Spouse Name

First

Last

Email *

Email

Confirm Email

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone *

Work Phone

Spouse Phone

Preferred method of contact: *

Home
Cell
Work

Preferred Method of Contact for Annual Exam/Vaccine Reminders:

Mail
Email

Would you be interested in receiving appointment reminders via email? *

Yes
No

Pet Information

First Pet’s Name *

First Pet is a: *

Dog
Cat
Other

Please Brief Other

Breed

Color

Sex/Altered

Date of Birth

Do you have an additional pet?*

Yes
No

Authorization

By 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

Pet Records

For existing clients only

Client & Pet Registration

Pet Information

Authorization

Dedicated to Helping You Keep Your Pets Healthy and Happy.

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