Are you new to us or a current client? (required) New Client (you MUST have an appointment scheduled with us already) Current Client Name(s) and relationship(s) of anyone who has permission to make medical decisions for your pet(s). E-Mail Address (required) : How do you prefer to receive appointment confirmations? (required) E-Mail Phone Call Text Message Which phone number can receive text messages? Primary Secondary How do you prefer to receive annual reminders for exams and vaccines? (required) E-mail Postcard If you are new to us, why did you select us? Referral Location Facebook Other Internet Source Is there someone we may thank for referring you?
Pet's Name (required) Age: Birth date or Years/Months Type of Pet (required) Canine Feline Breed: Sex: Male Female Neutered/Spayed Neutered Spayed Color Does your pet have a microchip? Yes No Do you have pet insurance? Yes No If Yes, please indicate the insurance company. Sometimes insurance companies will request records in order to verify a claim. Do we have your permission to provide records upon request? Please list any additional pets here 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) I Agree I Disagree 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) I Agree I Disagree