Client Registration Form – Welcome to Pembroke Animal Hospital

Client Registration Form

Todays Date

Home Phone Number

Mobil Phone Number

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Owner Date of Birth

Co-Owner First Name

Co-Owner Last Name

Co-Owner Phone Number

Communication Preferences: We will use your email and text to send you information including upcoming appointments, vaccines/treatments coming due, information on our online pharmacy, coupons and deals and to allow large animal owners access to important documents. *If you would not like to receive emails from our online pharmacy simply hit the unsubscribe button at the top or bottom of the email to opt out.

We will send appointment reminders via email, text and phone. We will send upcoming services due by email and text. If you would prefer to receive your services due reminders by postcard please check this box.

Send service reminders by postcard in the mail.

Are you over the age of 65 or active in the military? We offer a 10% discount.

Over the age of 65

Military

Photographs and video of patients and staff are taken on a regular basis for use by PAH for advertising, web/social media content and community/client education. Do you give consent to using your pets first name, breed, image and or story for purposes including advertising, web/social media content and community/client education?

How did you hear about our clinic?

If you were referred by a client of ours who can we send a thank you to?

Who was your previous Vet?

I authorize the release of my pets’ records to Pembroke Animal Hospital from the veterinarian listed above.

Pembroke Animal Hospital Financial Policy Pembroke Animal Hospital requires payment in full at the end of your pet’s visit and/or at time of discharge. For surgery or hospitalization a deposit may be required, and the balance is due upon your pet’s discharge from the hospital. We are happy to accept cash, check, money order, debit, Visa/Mastercard, American Express, Discover and Care Credit. New clients must make a New Client Deposit of $50.00 prior to their first initial visit. This deposit is only refundable up to the day before the scheduled visit. Same day cancellations, rescheduled appointments or no show appointments will forfeit the deposit and will need to make a new deposit to make a new appointment. All clients are responsible for full payment at the time of service unless specific arrangements are made prior to the start of your pet’s treatment. You are responsible for payment for all products and services rendered, even if a final bill is not completed at time of your visit. Accounts unpaid after 45 days from day of service are subject to being forwarded to an outside collection agency. Furthermore, any unpaid balance is subject to a 2% monthly (24% Annual) finance charge. If we have to submit your unpaid account to a collections process you will be responsible for all charges our practice incurs including late fees, finance fees, collection cost, staff costs, court filing fees and reasonable attorney’s fees. Any returned checks or credit card payments will carry a $30.00 service charge. I verify that the information I have provided is accurate. I authorize the veterinarians and staff of Pembroke Animal Hospital to examine, prescribe for, and treat my pets, and assume responsibility for all charges incurred in the care of my animals.

I have read and understand the financial policy of Pembroke Animal Hospital and agree to its terms

I have read and understand the financial policy of Pembroke Animal Hospital and agree to its terms. Please add your name to agree: