New Client Registration Form Welcome to Brunswick Veterinary Clinic! Please fill out this form in its entirety to help us prepare for your upcoming visit. Please note that we require New Client Registration Forms to be completed 24 hours PRIOR to your first appointment. If we do not receive this form 24 hours prior to your appointment, WE WILL NEED TO CANCEL AND RESCHEDULE YOUR APPOINTMENT. Pet Owner (Client) Please complete the information below. First Name Last Name Email By providing your email address, you are agreeing to receive emails regarding your pet's health, medical reminders and news about Brunswick Veterinary Clinic. Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country Primary Phone Secondary Phone Employer Driver's License Number Pet Owner Birthday How did you hear about us? --- Please select ---Internet SearchYelpFacebookInstagramReferral/Word of MouthOther Does this pet have a co-owner? Yes No Co-owner information First Name Last Name Address *If different from primary owner address. Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country Co-owner Phone Co-owner Email If a co-owner is no longer responsible for the care of your pet(s) in the future, you will need to contact us to have them removed from your pet's account. Once removed, they will no longer be contacted in regards to your pet's care. I understand and agree to contact Brunswick Veterinary Clinic if there is a change in co-ownership. Pet Information Please complete all information below. Pet Name Species Canine (Dog) Feline (Cat) Breed Color Sex --- Please select ---MaleNeutered MaleFemaleSpayed Female Birthday If an exact date is not known, an approximate birthdate is fine. Does this pet have any allergies or is there any significant information we should know? Are vaccinations current? Yes No Unknown What medications, preventatives or supplements, if any, is this pet currently receiving? If none, please say none. Has this pet been a patient of another veterinary clinic(s)? Yes No Please provide name and phone number of all previous veterinary clinics If you have a copy of this pet's veterinary records, please upload here Max. file size: 32 MB. May we contact your previous veterinarian for records? If you do not want us to contact your previous veterinarian, please use the file upload on this form or email your pet's records to [email protected] to provide all records prior to their appointment. A complete medical history is required for vaccination disbursement for new clients. Yes No Do you have a second pet? Yes No Second Pet Information Please complete all information below. Pet Name Species Canine (Dog) Feline (Cat) Breed Color Sex --- Please select ---MaleNeutered MaleFemaleSpayed Female Birthday If an exact date is not known, an approximate birthdate is fine. Does this pet have any allergies or is there any significant information we should know? Are vaccinations current? Yes No Unknown What medications, preventatives or supplements, if any, is this pet currently receiving? If none, please say none. Has this pet been a patient of another veterinary clinic(s)? Yes No Please provide name and phone number of all previous veterinary clinics If you have a copy of this pet's veterinary records, please upload here Max. file size: 32 MB. May we contact your previous veterinarian for records? If you do not want us to contact your previous veterinarian, please use the file upload on this form or email your pet's records to [email protected] to provide all records prior to their appointment. A complete medical history is required for vaccination disbursement for new clients. Yes No Do you have a third pet? Yes No As a new client, you can add up to two pets on your registration form. Additional pets can be added once your initial pet has become established with us. If you have any questions about this policy, please email [email protected]. Social Media Agreement Brunswick Veterinary Clinic occasionally features client pets on our social media accounts. By opting in, you give your consent for your pet(s) to be featured. We will never post medical or case photos or information without additional consent from you. Social Media Consent Yes, I consent. No, I do not consent. If your pet(s) has their own Instagram handle, please provide it below so we can tag them! Policy Confirmation Financial Policy: Payment is due in full at the time that services are rendered or performed. We do not bill or invoice for services. In-patient care is by written consent. We accept cash, check, Visa, Mastercard, Discover, and American Express payments. We do not extend credit. We also accept CareCredit (www.carecredit.com). All open invoices are sent to collections after 45-days. All insurance is third-party, and we do not prepare claims in house. We will send medical records to insurance companies by request. Any information that we collect is private and for our use only. Late Policy: We strongly believe in providing our clients and their pets the full attention and time with the doctors that they deserve. As such, if you are 10-minutes or more late to your appointment, your appointment will be forfeit and canceled. Depending on the capacity of our hospital, your appointment may be subject to rescheduling or indefinite postponing if no available new client appointments are available. Cancellation Policy: We understand that life sometimes gets in the way and you can't always make your scheduled appointment. To help us out, it is important for clients to give the hospital at least 24-hours notice prior to cancelling or rescheduling an appointment. Doing so ensures that we can make time available for another pet in need. Policy Agreement By checking this box, I indicate that as the owner of this pet(s) I understand and agree to Brunswick Veterinary Clinic's Financial, Late and Cancellation policies. Medical Record Release To prevent delay of services for insurance claims, we request your permission to share medical records when requested by an insurance company for your pet(s). Yes, I give my permission to share medical records as requested for my pet(s). No, I would prefer you email my records when requested by other parties and understand that care may be delayed until they have received my pet's records. Submit