Are you new to us or a current client? (required)
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Name(s) and relationship(s) of anyone who has permission to make medical decisions for your pet(s).
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E-Mail Address (required) :
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How do you prefer to receive appointment confirmations? (required)
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Which phone number can receive text messages?
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How do you prefer to receive annual reminders for exams and vaccines? (required)
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If you are new to us, why did you select us?
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Is there someone we may thank for referring you?
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Patient Information |
Pet's Name (required)
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Age: Birth date or Years/Months
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Type of Pet (required)
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Breed:
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Sex:
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Neutered/Spayed
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Color
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Does your pet have a microchip?
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Do you have pet insurance?
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If Yes, please indicate the insurance company.
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Sometimes insurance companies will request records in order to verify a claim. Do we have your permission to provide records upon request?
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Please list any additional pets here
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Please Read- Social Media Consent
I authorize Crossroads Animal Hospital, PC, to publish/display any photos/videos taken of my pet(s) in Crossroads Animal Hospital's facility or its publications (EX:website, Facebook, Instagram). *Please note, we will not use your first or last name in any post, just your pet's name.* |
I have read this statement and - (required)
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Please Read- Payment due at time of service(s)
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of Crossroads Animal Hospital and that charges are due and payable at the time of service. I understand that I can request a written estimate for goods and services provided to me by Crossroads Animal Hospital. I also understand that the acceptable forms of payment are cash, personal checks (processed electronically through TeleCheck and any checked returned unpaid will have a fee incurred), MasterCard, Visa, Discover and Care Credit. |
I have read this statement and - (required)
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