Primary Care Registration Form We are so excited to meet you! We look forward to helping you and your pet with Coral Springs Animal Hospital veterinary care. We just need some information to get started. Primary Care Registration Form Client Information Name * Name First First Last Last Email * *Information will not be sold or shared for mass email purposes -for hospital use only Primary Phone * Secondary Phone Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Employer Work Phone Secondary Owner Phone Emergency Contact * Phone * Pet Insurance Carrier Policy Number How did you hear about our hospital? Coral Springs Animal Hospital Client/Employee: (Please give us their name below, so we may thank them) Website Social Media AAHA Referral Location proximity to home Animal Control / Humane Society Search Engine (Google, Duck Duck Go, Yahoo, Bing, etc.) Heron Bay Living Magazine OtherOther Coral Springs Animal Hospital Client/Employee who referred you: Patient Information Pet's Name * Species * Breed * Pet's Color * Age/Date of Birth * Sex * MaleNeutered MaleFemaleSpayed Female Does your pet have a microchip identification? * Yes No What is the microchip number? Can Coral Springs Animal Hospital take photographs of this pet to use for social media, their website, and/or advertising? * Yes No Payment Policy ALL FEES FOR PROFESSIONAL SERVICES ARE DUE AND PAYABLE AT THE TIME SERVICES ARE RENDERED. It is our policy to provide you with a written estimate of fees if you wish, especially for any case where in-hospital or emergency care is necessary. A deposit prior to treatment is required. The balance is due at discharge. I agree, in the event that any amount becomes past due more than 30 days, I will pay interest thereon at 18% per annum (1.5% per month), plus a monthly billing charge of $5.00 from the date the charges were incurred. In the event it becomes necessary to collect fees through the services of an attorney or other collection agency, either prior to or at trial, I agree to pay all reasonable attorney’s fees and/or collection agency fees, and reasonable attorney’s fees incurred. I am the legal owner or the representative of the legal owner of the animal being presented for treatment, and I am over 18 years of age. Notwithstanding anything to the contrary above, if this Agreement is being signed by an Agent of the Authorized Person (for example, a pet sitter or pet transporter), it is agreed and understood that such Agent is NOT responsible for any fees related to the care and treatment of the pet. Only the Authorized Person and/or Co-Owner is responsible for such fees. Consent * I have read and accept the financial policy. Signature * signature keyboard Clear Date * Submit If you are human, leave this field blank.
