New Client Registration Form in Citrus Heights, CA | Summer Hills Veterinary Hospital

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This field is for validation purposes and should be left unchanged.

Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.

Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.

Owner's Name

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date of Birth*

Day-Time Phone*

Evening Phone

Mobile Phone

Email*

Enter Email Confirm Email

Co-owner's Name & Contact #

Name

First Last

Phone

How did you find out about our practice?*

If Personal Referral, is there someone we can thank for this referral?

Please use this area to give us any other relevant information about yourself or your family

Pet Information

Pet's Name*

Species*

or if other species

Breed (if known)

Color

Date of Birth or Age (if known)

Special Identification (tattoo, microchip, etc.)

Sex

Previous Veterinary Practice (if any)*

Previous Veterinarian (if any)

What vaccines were given at this time

Is your pet on any medication or supplement?

Yes
No

If Yes, please list the medication or supplement

Does your pet have allergies or drug reactions?

Yes
No

If Yes, please list the allergies and reactions

Are there any current or past medical conditions of which we should be aware?

Yes
No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Would you like to add another pet?

Yes
No

Cancellation / Missed Appointments Policy*

We ask that our clients provide a minimum of 24-hour notice for appointment rescheduling or cancellation. We require 24 hours' notice to cancel or change your appointment. If it is less than 24 hours or you are a "no show" to your appointment, you agree to be charged a $35 cancellation fee.

First Last

Appointment Date and Time*

Appointment Date and Time

Appointment Date Time

Signature*

By entering your name below, I agree to pay in full for all treatments provided to my pet(s) by Old Towne Animal Hospital. I understand that all fees are due at the time of service. Any charges left unpaid will be sent to collections.

Appointment Date Time

Date