Online Registration

 

Please complete the form below

Contact Information
Owner Name *
Owner Name
Spouse/Agent name
Spouse/Agent name
Address *
Address
Home Phone *
Home Phone
Cell Phone
Cell Phone
Work Phone
Work Phone
How did you learn About our Hospital
Patient Regsitration
Animal *
Birth Date
Birth Date
Authorization *
BY SUBMITTING THE ABOVE I HEREBY AUTHORIZE THE VETERINARIAN(S) AND STAFF OF FAMILY DOG AND CAT HOSPITAL TO EXAMINE, PRESCRIBE FOR AND/OR TREAT THE ABOVE DESCRIBED PET. I ASSUME FULL FINANCIAL RESPONSIBILITY AND AGREE TO PAY THE BALANCE DUE IN FULL AT THE TIME SERVICES ARE RENDERED OR UPON MY PET’S RELEASE FROM THE HOSPITAL. AN ESTIMATE FOR SERVICES CAN BE PROVIDED AT MY REQUEST PRIOR TO TREATMENT.

Our Payment Policy

We accept the following forms of payment: Cash, Check (I.D. required), American Express, Discover, Visa and Mastercard. Payment Plans are available through CareCredit. We reserve the right to ask for a deposit before services are rendered.

Authorization

By submitting the above I hereby authorize the veterinarian(s) and staff of Family Dog and Cat Hospital to examine, prescribe for and/or treat the above described pet. I assume full financial responsibility and agree to pay the balance due in full at the time services are rendered or upon my pet’s release from the hospital. An estimate for services can be provided at my request prior to treatment.