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Three Springs Animal Hospital - New Patient Registration

Owner Information:

Full Name

Phone Number

Email Address

Home Address

Apartment Number

City / State

Pet Registration:

Pet Name

Species

Species

Breed & Color

Gender

Gender

Fixed

Fixed

Pet's Birthday / Gotcha Day

Vaccination History

Vaccination History

Medical History / Concerns (Check all that apply)

Medical History / Concerns (Check all that apply)

Marketing Release:

I grant Three Springs Animal Hospital permission to post my pet’s picture, name, and story to social media, TSAH website, and use for marketing purposes.

I grant Three Springs Animal Hospital permission to post my pet’s picture, name, and story to social media, TSAH website, and use for marketing purposes.

Continue Registration:

Register a Second Pet?

Register a Second Pet?

Medical Records Release:

I authorize the release of my pet’s medical records to Three Springs Animal Hospital.

I authorize the release of my pet’s medical records to Three Springs Animal Hospital.

Where are your current medical records located?

Payment Authorization:

In the event that charges incurred are not paid in full at time of service and collection action is instituted within 90 days, whether by a collection agency, attorney or both, I agree to be responsible for and to pay, in addition to the charges for services, treatment and goods received, all costs associated with such collection activity including but not limited to reasonable interest, collection agency fees, attorney fees and court costs. 

You agree to reimburse us the collection fees of any collection agency, which shall be based on a percentage at a maximum rate of 33 1/3% of the amount due at the time your account is placed with collection agency, and all costs and expenses incurred for any collection efforts on your account, including reasonable attorney’s fees incurred by the collection agency. This contract shall cover all medical treatments and services until revoked by either party in writing.

Signature

How did you hear about us?

How did you hear about us?