Forms Name Owner Spouse/Other Mailing Address Street Address City State / Province / Region ZIP / Postal Code Street AddressPlease list the street address if the mailing address is P.O. Box:Home PhoneCell PhoneEmployer Information Employer Work Phone Best Email Address to send appointment notes and reminders to: Spouse/Other Information Spouse/Other Employer Spouse/Other Work Phone Emergency Information Emergency Contact Emergency Phone How did you hear of us, from a friend or family member? (Please let us know their name so you both receive $20 referral credit.)Or did your hear about us from: ad in paper ad on radio Yellow pages internet Why did you choose to use our service? price quality convenience reputation How are you planning to pay today? Cash Check Charge (VISA, MasterCard, Discover) Care Credit Do you have pet insurance?YesNoIf yes, who is the provider?May we send a text to the cell phone number provided above to confirm appointments and remind you of services that are coming due?YesNoAre you at least 18 years of age?YesNoIf no we will need parent or guardian authorization to treat your pet(s).Please list all Pets in household:Authorization I hereby authorize the Doctors of At Home Veterinary Care to examine, prescribe medication for and/or treat the pet(s) listed on my account. I assume responsibility for all charges incurred in the care of this/these animal(s). I understand that payment is due at the time of service and that a deposit may be required for some treatments. If we invoice you, invoices are due and payable upon receipt. Accounts over 30 days past due are subject to 1.5% interest. If your account is placed for outside collection, you are responsible for all costs of collection. I also grant At Home Veterinary Care permission to post my pet(s) picture, story and medical information on social media. I also understand that there are closed-circuit cameras in each exam room. Printable Registration Form