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New Patient Registration Form Claremont Animal Hospital

Save time during your next appointment! Complete your required form online from any device at any time before your visit.

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New Client Form

Thank you for allowing Claremont Animal Hospital the opportunity to care for your pets. So that we may become better acquainted, please complete the following:

Client Information

Name *

First

Last

Email *

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is your physical address different than your mailing address? *

Street Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Alt Phone

Place of Employment

Best time to reach you *

Drivers License #

Patient Information

Name *

Sex *

Color *

Breed *

My pet is:

A member of our family
Child's Pet
Backyard Pet

Any allergies to vaccinations or medication? *

Any previous serious illnesses or surgeries? *

Is your pet on any special diets or medications? *

Would you like to be present during treatment to your pet? *

Payment Policy *

I have read and agree to payment policies.

ALL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. FAILURE TO KEEP APPOINTMENTS MAY RESULT IN A NO-SHOW FEE. The customer agrees that any amount unpaid after thirty days will be subject to interest at the rate of 18% per year (1.5% per month) until such unpaid amount is paid in full. Additionally, the customer will be responsible for the reasonable cost of collection of any such unpaid amounts, including collection of any attorney's fees. Accounts with outstanding balances may be refused services.

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