Patient Information

Thank you for giving us the opportunity to care for your pet.
We will be happy to answer any questions you may have about your pet’s health. To ensure the best care possible, please take the time to fill out this form.
Thank You!

Registration

Name of Owner

Mailing Address

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

E-Mail Address

Would you like E-Mail reminders?

Yes

Spouse

Spouse Work

Spouse Cell

Emergency Contact Name

Phone

Previous Veterinarian

Phone

How did you learn about our clinic?

Recommended

Recommended by whom?

Yellow pages

Sign

Internet/Facebook

Yelp

Other

If other please explain

Pet Health History

Name of Pet

Dog

Cat

Other

Breed

Color

Birth Date

Gender

Male

Male Neutered

Female

Female Spayed

Major Surgeries or Medical Illnesses

Current Medications (including vitamins/supplements)

Current Diet (Including Treats)

Pet Health History

Name of Pet

Dog

Cat

Other

Breed

Color

Birth Date

Gender

Male

Male Neutered

Female

Female Spayed

Major Surgeries or Medical Illnesses

Current Medications (including vitamins/supplements)

Current Diet (Including Treats)

Pet Health History

Name of Pet

Dog

Cat

Other

Breed

Color

Birth Date

Gender

Male

Male Neutered

Female

Female Spayed

Major Surgeries or Medical Illnesses

Current Medications (including vitamins/supplements)

Current Diet (Including Treats)

Pet Health History

Name of Pet

Dog

Cat

Other

Breed

Color

Birth Date

Gender

Male

Male Neutered

Female

Female Spayed

Major Surgeries or Medical Illnesses

Current Medications (including vitamins/supplements)

Current Diet (Including Treats)

Our payment policy requires payment in full at the end of your appointment.
Payment options include:
*Cash
* Check
*American Express
*Visa
*Mastercard
*Discover
*Care Credit

If checks are returned to Green Valley for Not-Sufficient Funds (NSF), the client will incur a charge of $35 to their account.
Payment with cash or credit card is required to settle the account.
If you have an outstanding bill, we cannot provide additional services until the past-due balance is paid in full.

Authorization

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet.
I assume responsibility for all charges incurred in the care of this animal.
I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment.

Date

E-Signature

Please sign electronically below.

Click submit and you hereby give consent to sign this document electronically.

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