New Client Registration Form – Kensington Bird & Animal Hospital

Date*

Date Format: MM slash DD slash YYYY

Your Name*

First Last

Pet's Name*

Species*

Address*

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

Primary Phone*

Secondary Phone*

Other Phone*

Email*

Preferred method of communication for veterinarian follow up calls?*

Secondary Contact:*

Spouse
Co-Owner
N/A

Name*

First Last

Phone*

Email*

Address*

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

Have you ever been to our clinic before?*

Yes
No

Consent*

I agree to the policy.

I assume full responsibility for all charges incurred in the care of my animals. I understand that full payment is expected at the time services are rendered. I also understand that, should my pet require hospitalization, a deposit will be required prior to admission and that further deposits may be required during the course of hospitalization. I will pay any remaining charges in full at the time of my pet's release from the hospital. I understand that no guarantee is made regarding the outcome of any diagnostics or treatment performed. I understand that I have the right to decline any of the diagnostics or treatments recommended by the attending veterinarian. I understand that I am making an informed financial commitment for the care of my pet and agree to assume full financial responsibility for all fees incurred by treatment, regardless of the outcome. I understand that if I default on payment, I will agree to pay all fees associated with collection of the debt. I understand that there is a monthly billing fee of 1.5% on all outstanding balances. I understand that in the event that I do not meet my responsibilities outlined herein, Kensington Bird and Animal Hospital will employ a credit collection agency to collect my unpaid debt. I have read, understand, and agree to the above terms fully and hereby authorize the veterinarians and their support staff to examine and treat any and all pets I bring to Kensington Bird and Animal Hospital from here on.

Consent*

I am 18 years old or older

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If you have an emergency with your pet, please call us immediately at 860-828-7736

THIS IS NOT FOR MAKING AN APPOINTMENT. PLEASE CALL THE OFFICE AT 860-828-7736.

Client Registration Form

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