Longenbaugh Veterinary Hospital

New Clients

In order to expedite your check-in procedure, we are pleased to provide you with a new client form. You can print the form and bring it with you or you may submit the form directly from our website. In order for a submitted form to serve as a signed form, you must check the "I agree box" on the form. Only an owner of the pet can give authorization for services.  If you wish more than one person to have the right to pick-up, drop-off or make payment for services, please list this person as a co-owner or agent of owner.  Thank you.  If you have any questions, please call us at 281-856-7023.                                                                            
 

Form - New Client

Only an owner/co-owner/ agent of owner may give authorizations for services,
or receive medical information regarding this pet.
Owner's Name (required)
First Name (required)
Last Name (required)
Co-Owner's Name
First Name
Last Name
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address (required) :
Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed/Color:

Sex: (required)
Male
Female

Neutered/Spayed
Neutered
Spayed

Are your pets vaccines current?
Do you have pets medical records?
Medical records at another veterinary Practice?
Yes
No

Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No

Would you like us to call you for your appointment
Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Longenbaugh Veterinary Hospital and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge. Any balance that I leave unpaid will be forwarded to Longenbaugh Veterinary Hospital's collection agency, and will incur a collection fee for which I am liable, in addition to monthly finance charges.
I have read this statement and -
I Agree
I Disagree


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