New Client Registration Form

Information About You

Have you been to Cahuenga Pet Hospital before?
YesNo

Primary Owner's Name

Street Address:

Apt./Suite #:

City, State:

Zip Code:

Home Phone:

Work Phone:

Cell Phone:

Email Address:

Secondary Email Address:

Spouse/Emergency Contact Name:

Spouse/Emergency Contact Phone:

Driver's License #:

State of Driver's License:

Expiration Date:

Date of Birth:

Employer Name:

Employer's Phone Number & Ext.:

Employer Address:

How did you find us?
FriendSignYellow PagesWebsiteInternetPet ShopWalk InFlyerNewspaperOther

If referred by someone, please enter their name so we may thank them:


Information About Your Pet

Pet's Name

CanineFeline

MaleFemaleSpayedNeutered

Date of Birth:

Breed:

Color(s):

Last Rabies Vaccine:

Please check off the conditions your pet has been vaccinated against in the past year:
RabiesDistemperHeartworm PreventionFeline Immunodeficiency Virus (FIV)Feline Infectious Peritonitis (FIP)LeptospirosisLyme DiseaseParvovirus

Has your pet ever had an adverse drug reaction?
YesNo

If yes, please explain:


Payment Terms

We accept Cash, Visa, MasterCard, Discover, Debit ATM Cards and Care Credit. Payment of the entire medical treatment plan is required on all patient admissions, and the balance, if any, is due upon patient discharge.

YesNo

By selecting yes, I agree to make prompt and complete payment upon discharge of my pet(s).


Patient Agreement

I/we hereby authorize Pulse Animal Medical Center, Inc., DBA Cahuenga Pet Hospital and all assistants of its choice to administer any medical and/or surgical treatments/procedures as is considered therapeutically and/or diagnostically necessary. I further understand that no guaranty of successful treatment is made. I/we hereby release Pulse Animal Medical Center, Inc., Cahuenga Pet Hospital, and all its personnel or assistants, from any liability by any reason of any act hereinabove authorized. I assume full financial responsibility for all charges incurred for the care and treatment of my pet(s). I further understand that if I fail to pay the entire amount, a monthly service charge of 1.5% will be added to any unpaid balances over 30 days. If my account is turned over to a collection agency, I agree to pay 40% of the unpaid balance as collection fees in addition to the principle amount owed. I further agree to pay reasonable attorney fees and court costs arising out of any litigation concerning the collection of this account. I hereby authorize the collecting practice to obtain credit reports on me. I consent to release all above information to any collection agencies as may be deemed necessary by the management. I also understand that if I neglect to pick up the above animal within the time required by Sec.1834.5 and 1834.6 (14 days after it is due to be pick up) California Civil Code, shell be deemed abandoned by owner and will be disposed of according to Sec. 1834.5 of the California Civil Code. In doing so, I understand that this does not relieve me from my financial obligation.

YesNo

By selecting yes and entering my name below, I acknowledge that I have read the foregoing and agree.

Owner/Agent

Date

Time