Primary Owner *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Phone Type *

Home
Work
Mobile

I consent to receive SMS text messages from Cottage Pet Hospital. Msg & data rates may apply. Reply STOP to opt-out. *

Yes
No

Secondary Phone

Phone Type

Home
Work
Mobile

Can we send you text message notifications? *

Yes
No

If yes, phone number: *

Email *

Secondary Owner

First

Last

Phone

Please tell us how you prefer to pay your bill *

Please note: if paying by check we require both a Valid Driver’s license/State I.D. AND Social Security number. If paying by card we require a Valid Driver’s license/State I.D.

How did you learn about our hospital? *

Which internet source? *

If other site, please list *

Name of friend or relative (so we know who to thank) *

If other, please list *

New Patient Registration

Pet's Name *

Species *

Dog
Cat

Breed *

Age/Date of Birth *

Color/Markings *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number? *

Reason for today's visit *

Previous Doctor/Hospital Name *

May we request records? *

Yes
No

Previous Medical History/Treatment/Surgery *

Vaccination History *

Do you have pet insurance? *

Yes
No

If yes, which company? *

I, the undersigned, owner or authorized agent of the above patient, hereby authorize the admitting veterinarian (and his designated associates or assistants) to administer such treatment as needed for the benefit of this patient. I also consent to the administration of such anesthetics as needed. I DO / DO NOT AUTHORIZE ADDITIONAL TREATMENT (IF NEEDED) SHOULD I BE UNABLE TO BE REACHED. *

I DO authorize additional treatment
I DO NOT authorize additional treatment

I further understand that no guarantee of successful treatment is made. I also assume financial responsibility for all charges incurred to this patient, and agree to pay all such charges at the time the patient is released. If any portion of the bill is not paid in full within one month, there will be a monthly finance rate of 1.5% and a $4.00 billing charge for each month it remains unpaid. You are responsible for all fees including 25% collection fee if your account is sent to collections and/or court fees. PAYMENT IS DUE AT TIME OF SERVICE. *

I have read and agree to the financial terms

Signature of Primary Owner/Agent *

Date *

Signature of Secondary Owner/Agent

Date

Online Forms

New Client Form

New Client Form

New Patient Registration

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