Registration form

Fort Plain Animal Hospital
      Client-Patient Registration Form

Owners name____________________________ Spouse/partner_____________________
Address__________________________________________________________________
City_____________________________________________ State______ Zip Code______
Home Phone (_____) ________________   Cell Phone (______) _____________________
E-Mail Address____________________________________________________________
Employer_______________________________ Work Phone_______________________
Social Security # ______-_____-______ Drivers License # ________________State______

• If a friend/neighbor/co-worker referred you please be sure to fill in their name-referring clients
are awarded a discount!!______________________________________________________
• What are your expectations in veterinary care for your pets? _________________________________________________________________________

Payment Information:  We accept cash, Visa, Mastercard, Discover, Care Credit and personal or business checks.  All fees incurred at Fort Plain Animal Hospital are to be paid at the time services are rendered.  Any outstanding balance is subject to a 1.5% monthly charge.  there is a #30.00 returned check fee.  should the services of a collection agency be required, the client assumes all associated costs.

  I prefer to pay by:  Cash________ Check_________     Credit Card________
(If check is your preferred method, please present your drivers license)

I have read and understand the payment information *______________________________________*
                                                                                         Signature                                             Date

Pet # 1                                              Pet #2                                       Pet #3
Name__________________            Name___________________  Name_____________________
Breed__________________            Breed___________________  Breed_____________________
Color__________________            Color___________________  Color_____________________
Birth Date______________             Birth Date________________  Birth Date__________________
Sex: Male / Female                           Sex: Male / Female                     Sex: Male / Female
Neutered / Spayed                           Neutered / Spayed                     Neutered / Spayed

Pet # 4                                             Pet # 5                                      Pet # 6
Name__________________           Name___________________  Name_____________________
Breed__________________           Breed___________________  Breed_____________________
Color___________________         Color____________________  Color_____________________
Birth Date_______________          Birth Date________________  Birth Date_________________
Sex: Male / Female                          Sex: Male / Female                    Sex: Male / Female
Neutered / Spayed                           Neutered / Spayed                    Neutered / Spayed