New Patient Registration FormStep 1 of 333%Thank you for choosing Stoney Creek Veterinary Hospital! We are pleased to welcome you and your family to our practice. Please take a few minutes to fully complete this form so we may better serve you. We look forward to a long and rewarding relationship with you and your pet(s).Owner's First And Last Name* First Last Email* Spouse/OtherAddress* Street Address City State ZIP / Postal Code Best Phone Number To Reach You*Secondary PhoneSpouse/Other Cell PhoneSpouse/Other Work PhoneHow Did You Find Out About Us*Click To Select An OptionA Friend Or Relative Recommended The PracticeI Drove By And Saw Your SignI Saw The Practice In The Yellow PagesFound Your In The Search EnginesOtherOtherWill You Allow Us To Share Pictures And Updates Of Your Pet On Facebook?*YesNoHow Would You Like To Receive Reminders*MailEmailPrevious VeterinarianPrevious Veterinarian Phone NumberYour Pet's InformationYour Pet's Name*Do You Know Your Pet's Date Of Birth?*YesNoPet's Date Of Birth* Date Format: MM slash DD slash YYYY What Is Your Pet's Approximate Age?*Species*Click To SelectCanineFelineOtherOtherBreed*Color*Neutered Or Spayed*Click To SelectMaleMale NeuteredFemaleFemale SpayedKnown AllergiesTatoo/Microchip*YesNoDo You Have A Second Pet You Need To Fill Out Information For?*YesNoYour Other Pet's NameDo You Know Your Pet's Date Of Birth?YesNoDate Of Birth Date Format: MM slash DD slash YYYY What Is Your Pet's Approximate Age?SpeciesClick To SelectCanineFelineOtherOtherBreedColorNeutered Or SpayedClick To SelectMaleMale NeuteredFemaleFemale SpayedKnown AllergiesTatoo/MicrochipYesNoDo You Have A Third Pet You Need To Fill Out Information For?YesNoYour Other Pet's NameDo You Know Your Pet's Date Of Birth?YesNoDate of Birth Date Format: MM slash DD slash YYYY What Is Your Pet's Approximate Age?SpeciesClick To SelectCanineFelineOtherOtherBreedColorNeutered Or SpayedClick To SelectMaleMale NeuteredFemaleFemale NeuteredKnown AllergiesTatoo/MicrochipYesNoDo You Have A Fourth Pet You Need To Fill Out Information For?YesNoYour Other Pet's NameDo You Know Your Pet's Date Of Birth?YesNoDate Of Birth? Date Format: MM slash DD slash YYYY What Is Your Pet's Approximate Age?SpeciesClick To SelectCanineFelineOtherOtherBreedColorNeutered Or SpayedClick To SelectMaleMale NeuteredFemaleFemale SpayedKnown AllergiesTatoo/MicrochipYesNoDo You Have A Fifth Pet You Need To Fill Out Information For?YesNoYour Other Pet's NameDo You Know Your Pet's Date Of Birth?YesNoDate Of Birth? Date Format: MM slash DD slash YYYY What Is Your Pet's Approximate Age?SpeciesClick To SelectCanineFelineOtherOtherBreedColorNeutered Or SpayedClick To SelectMaleMale NeuteredFemaleFemale SpayedKnown AllergiesTatoo/MicrochipYesNoYour Name* First Last Date Date Format: MM slash DD slash YYYY Any Additional Information You Would Like Us To KnowThe information on this form is strictly confidential and is to be used only by this practice to provide care and treatment for your pet.We will gladly provide a written estimate if you desire (Please ask our doctors or receptionists). This will be important to you since ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. In cases of extensive medical or surgical procedures when full payment may be difficult at discharge we also take MasterCard, Visa, Discover and Care Credit. There will be a service charge for any check that is returned unpaid.To prevent the spread of infectious diseases all hospitalized, boarding and grooming patients must be current on all vaccines and the appropriate charges will be accessed in the discharge invoice. By checking the box below, you acknowledgment that you understand the above payment policy.Check here if you accept these terms.* I Accept These Terms
