Registration Form

Client Information

Name*

First Last

Address*

Street Address City State ZIP Code

Email*

Phone*

Work Phone

Date of Birth

Driver's License #*

Spouse / Partner Information

If applicable

Name

First Last

Address

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

Phone # 1

Phone # 2

Date of Birth

Driver's License #

Pet Information

Pet Name

Breed

Color

Species

Canine
Feline

Sex

Male, Intact
Male, Neutered
Female, Intact
Female, Spayed

Birthdate

Age

Microchip #

Vaccination History

Previous Veterinarian/Hospital (name/address/phone)

Owner’s Responsibility

Payment is required for all services at the time they are rendered unless prior arrangements have been made with hospital management. In the event that a refund is due and the original payment is a credit card, the refund will be posted against the original credit card. All returned checks are subject to a $25.00 service fee. A 90-day old account balance is subject for collection efforts and a $25.00 collection fee will be assessed. Your signature below signifies your understanding and willingness to comply with the hospital’s payment terms. In some cases, a deposit may be required before proceeding.

Veterinary Consent: I authorize Erickson Veterinary Hospital to perform the treatment/procedure(s) described in my pet’s chart. I will be informed of the reasons for the treatment/procedure(s), along with the expected benefits and risks involved. I understand that unforeseen conditions may require an extension of a planned procedure and/or surgery. I hereby authorize the performance of such procedures or surgeries as are necessary and advisable in the professional judgment of EVH veterinarians or a relief veterinarian. I understand that I assume all risks and am responsible for all costs involved. I also authorize EVH to use pictures of my pet(s) for promotional purposes. Consent will apply to all future pets added to this account unless and until I provide a written revocation of that consent.

Missed/Cancellation Fee: A fee of $50 will be assessed on your client account if you fail to show up for an appointment without an email or phone call or cancel without at least a 24 hour notice.  

Surgical Appointment, No Show Policy A $100 charge will be charged for any missed/cancelled surgical appointment without at least a 24 hour notice. This applies for dental procedures as well.

Phone Call Recordings*

I understand and consent to any phone calls between myself and representatives at Erickson Veterinary Hospital being recorded.

By signing this agreement, you acknowledge the importance of maintaining a mutually respectful and professional environment. We reserve the right to discontinue services if any form of mistreatment, disrespect, or inappropriate behavior towards our team occurs.

Signature*

Client Information

Spouse / Partner Information

Pet Information

Owner’s Responsibility

Contact Us

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