New Client Registration Form

Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.

Primary Owner

Primary/Mobile Number

Additional Authorized Owner Name

Additonal Authorized Owner Number

Address

City

State

ZIP / Postal Code

Who can we thank for the referral?

Pet's Name

Sex

Date of Birth (if known)

Breed

Color

Medical History

Please have your pet's previous medical records emailed to info@philadelphiaanimalhospital.com prior to your appointment.
Our team likes to review test results, vaccine history, and learn more about your pet to help prepare for the visit.

I authorize the veterinarians at Philadelphia Animal Hospital to examine, diagnose, and provide medical or surgical care for the pet(s) listed above. I understand that I am financially responsible for all services provided.

Payment is due at the time of service. A deposit may be required for hospitalized patients or surgical procedures.

By entering your full name below, you are providing your electronic signature and acknowledging that you have read and agree to the terms outlined in this form.

Signature

Name

Date

We accept Cash, Check, Visa, MasterCard, Amex, Discover, and CareCredit*
*Based on approval (if interested in CareCredit, please ask the front desk!)

New Client Registration Form

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New Client Registration Form

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