New Client Registration Form Download and Print FormClient InformationName* First Last Spouse First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Spouse PhoneEmployer*If necessary, may we contact you at work?* Yes NoFax Number, if applicableEmail Address* Providing us with your email address will allow us to communicate with you in the event that we cannot reach you by telephone. Also, you will be able to access your pet portal through our website! There, you will be able to access your pet’s health information, access our online pharmacy, request appointments, received reminders, and more!How did you hear about us? Who/what may we thank for referring you?*What is your preferred method of being contacted?* Email Phone call Text Patient InformationPatient Name* First Last Species*Breed*Date of birth*Sex* Male Female Spayed NeuteredColor*Is your pet on heartworm prevention?* Yes NoWhat type/brand:*Is your pet on flea prevention?* Yes NoWhat type/brand:*Has your pet been tested for viruses?* Yes NoWhat was the test date and results?*Are there any other pets in your household?* Yes NoHow many and what species?*Previous medical records can be obtained from:Add another pet? Yes NoPatient Name* First Last Species*Breed*Date of birth*Sex* Male Female Spayed NeuteredColor*Is your pet on heartworm prevention?* Yes NoWhat type/brand:*Is your pet on flea prevention?* Yes NoWhat type/brand:*Has your pet been tested for viruses?* Yes NoWhat was the test date and results?*Are there any other pets in your household?* Yes NoHow many and what species?*Previous medical records can be obtained from:Owner’s Right to PrivacyTexas Veterinary Licensing Act prohibits the disclosure of your name, address and your pet’s health care records (including rabies and other vaccinations) to anyone, without your authorization.Would you allow us to release immunization records to boarding kennels and grooming facilities?* Yes NoWould you allow us to release your name, address and phone number(s) to someone who has found your lost pet(s)?* Yes NoDo you grant Forest Crossing Animal Hospital permission to use photos/videos of your pet on social media and/or for promotional purposes?* Yes NoDo you have pet insurance? Ask us how we can help you submit your claims!* Yes NoFinancial PolicyThank you for choosing FOREST CROSSING ANIMAL HOSPITAL. Our primary mission is to deliver the best and most comprehensive veterinary care available for your pet. An important part of the mission is making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options. FOREST CROSSING ANIMAL HOSPITAL requires payment in full at the end of your pet’s examination and/or at the time of discharge.Payment OptionsCash, Visa®, MasterCard®, American Express®or Discover Card®Convenient Monthly Payment Options¹ from the CareCredit® Healthcare CreditCardo Allow you to begin treatment today and pay over timeo Available for any treatment amount greater than $1000o $1000 or more can utilize 6 months no interesto $2000 or more can utilize 12 months no interesto Can be used repeatedly – for your entire family – without having to reapply¹Deposit & BillingFor some treatments or hospitalized care, a deposit may be required. Healthcare plans requiring comprehensive care of , will require a 50% deposit to begin your pet’s treatment. We may offer in-house payment options on a case-by-case basis. We charge 24% interest on all outstanding account balances older than 90 days. If you have an account 120 days past due, FOREST CROSSING ANIMAL HOSPITAL may relinquish your balance owed to a collection agencyAdditional Policy InformationA fee of $50 may be charged for clients who miss or cancel more than 5 appointments in a calendar year without 24 hours notice. For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier.If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your pet.By signing below, you agree to the foregoing terms of payment:Financial PolicyFinancial Policy Thank you for choosing FOREST CROSSING ANIMAL HOSPITAL. Our primary mission is to deliver the best and most comprehensive veterinary care available for your pet. An important part of the mission is making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options. FOREST CROSSING ANIMAL HOSPITAL requires payment in full at the end of your pet's examination and/or at the time of discharge. Payment Options Cash, Check, Visa®, MasterCard®, American Express®or Discover Card® Convenient Monthly Payment Options¹ from the CareCredit® Healthcare CreditCard o Allow you to begin treatment today and pay over time o Available for any treatment amount greater than $1000 o $1000 or more can utilize 6 months no interest o $2000 or more can utilize 12 months no interest o Can be used repeatedly – for your entire family – without having to reapply¹ Deposit & Billing For some treatments or hospitalized care, a deposit may be required. Healthcare plans requiring comprehensive care of , will require a 50% deposit to begin your pet's treatment. We may offer in-house payment options on a case-by-case basis. We charge 24% interest on all outstanding account balances older than 90 days. If you have an account 120 days past due, FOREST CROSSING ANIMAL HOSPITAL may relinquish your balance owed to a collection agency Additional Policy Information FOREST CROSSING ANIMAL HOSPITAL charges $35 for returned checks. A fee of $50 may be charged for clients who miss or cancel more than 5 appointments in a calendar year without 24 hours notice. For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier. If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your pet.Signature*CAPTCHAΔ
