New Client Registration Form

Owner Name*

First Last

Address*

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

Day-Time Phone*

Evening Phone

Mobile Phone

Email*

Enter Email Confirm Email

Driver's License*

Please enter your driver's license number and state of issue. This identity confirmation requirement aids us if there are any payment issues.

Co-Owner Name

First Last

Co-Owner Phone Number

How did you find out about our practice?

If someone referred you, let us know who they are so we can thank them!

Pet Information

Pet's Name*

Species*

Species (if other than listed above)*

Breed (if known)

Color

Date of Birth or Age (if known)

Sex

Name of Former Veterinary Practice (if any)

Is your pet on any medication or supplements?

Yes
No

Medication or Supplement Information

Please list any medications and how many times a day your pet takes them

What food does your pet eat?

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

Please use the following box to give us any other information about your pet that you feel we should know.

Pet Records Upload

Do you have records for your pet? Upload them here.

Consent*

Fees are structured to support the most progressive, quality veterinary services possible. We encourage you to ask our receptionists about the cost of general services, as well as to review and discuss with your doctor the estimate for your pet’s treatment plan, so that you are best informed to make necessary decisions. Radnor Veterinary Hospital is committed to providing comprehensive veterinary services for your pet. We understand that at times it may be necessary to discuss alternate forms of treatment. We are happy to help you explore alternatives in order to arrive at the best plan for your family and pet. Fee estimates are approximations of expected medical costs and can vary significantly. We will attempt to contact you regarding significant change in treatment/fees as they occur. Payment is expected at the time services are rendered. All charges must be paid in full prior to discharge. We accept cash, personal checks, Mastercard, Visa, Debit, Amex and Discover. Please make checks payable to Radnor Veterinary Hospital, LLC. We have the right to refuse any personal check. We do not accept post-dated checks. There is a $40.00 returned check fee. Collection actions are actively pursued by RVH. Balances over 30 days accrue interest at a rate of 1.5% per month.

I have read and agree to the requirements detailed above for all of my pets under Radnor Vet Hospital's care.

Date*

Pet Information

HOSPITAL HOURS

DOG CLUB HOURS

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