Owner's Name *

First

Last

Spouse/Other

Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Secondary Phone

Additional Phone

Email *

By providing this, we will be able to communicate reminders for your pet to you and you will have access to online records, our app/loyalty program, and specials. Be assured that your email is kept private as is the rest of your information.

Driver's License #

State

Owner DOB

Employer

How did you hear about us?

If recommended, who can we thank?

Please list all individuals authorized to request treatment for your pet(s)

Pet Information

Pet's Name

Species

Cat
Dog
Other

If other, please specify

Breed

Color

Sex

Male
Female
Neutered Male
Spayed Female

Age or Date of Birth

Microchip #

Would you like to add another pet's information? *

Yes
No

Pet's Name

Species

Cat
Dog
Other

If other, please specify

Breed

Color

Sex

Male
Female
Neutered Male
Spayed Female

Age or Date of Birth

Microchip #

Would you like to add another pet's information? *

Yes
No

Pet's Name

Species

Cat
Dog
Other

If other, please specify

Breed

Color

Sex

Male
Female
Neutered Male
Spayed Female

Age or Date of Birth

Microchip #

Previous Veterinarian

I hereby authorize the veterinarians at Skyview Animal Clinic to examine, prescribe for, and treat the above described pet(s). Any animal admitted or hospitalized shall receive the necessary diagnostic tests and treatment to ensure proper medical care. I agree to pay for all services rendered and medications, goods, and supplies when purchased. I understand that a deposit may be required for surgical or medical treatment. ALL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. *

I have read and understand

I hereby grant Skyview Animal Clinic permission to use my likeness and/or my pet’s/pets’ likeness in photograph(s)/video(s) in any and all of its publications and other media. This release relates to photographs/videos intended for use in any hospital publication or a marketing or public relations nature, such as newsletters, brochures, websites/blogs/social networking sites, promotional items or other such material. I will make no monetary or other claim against Skyview Animal Clinic for the use of photographs(s)/video(s). *

I have read and understand

You agree, in order for us to service our account or to collect any amounts you may owe, we may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable. We may also contact you by sending text messages or e-mails, using any e-mail address you provide to us. *

I have read and understand

All information collected from you will be kept confidential except in cases of legal action or in order to collect any debt. By my signature below, I hereby agree to all of the above and acknowledge the receipt of a copy of this agreement (upon request). *

I have read and understand

Digital Signature *

Date *

New Client Registration

Pet Information