New Client Registration Form - Gotham Veterinary Center

OWNER’S NAME: *

First

Last

SPOUSE/PARTNER:

First

Last

ADDRESS/CONTACT INFO:

Address

Apt

City

State

Zip

Email *

Home Phone

Cell Phone *

Work Phone

Spouse/Partner Phone

EMERGENCY CONTACT: (We need this number in case we are not able to reach you.)

Name *

Phone *

Relationship *

PET INFORMATION:

Name *

Date of Birth//

Sex *

Male
Female

Species *

Feline
Canine

Breed

Spay/Neutered

Color

Microchip

Yes
No

Do we have your permission to share your pet(s) image and story on social media, our website and other forms of related media? Your name and personal information will never be shared. *

I authorize photo use.
I do not authorize photo use.

HOW DID YOU HEAR ABOUT US?

Other

Office Payment Policy: Payment is due when services are rendered We accept cash, check, and all major credit cards as forms of payment. We offer CareCredit (6 month interest free financing) and ScratchPay (financing alternative)

Additional Pet Registration

Name

Date of Birth//

Sex

Male
Female

Species

Feline
Canine

Breed

Spay/Neutered

Color

Microchip

Yes
No

Name

Date of Birth//

Sex

Male
Female

Species

Feline
Canine

Breed

Spay/Neutered

Color

Microchip

Yes
No

Name

Date of Birth//

Sex

Male
Female

Species

Feline
Canine

Breed

Spay/Neutered

Color

Microchip

Yes
No

Name

Date of Birth//

Sex

Male
Female

Species

Feline
Canine

Breed

Spay/Neutered

Color

Microchip

Yes
No

Name

Date of Birth//

Sex

Male
Female

Species

Feline
Canine

Breed

Spay/Neutered

Color

Microchip

Yes
No