Client Registration Form

If you’re looking for elevated specialty care for your pet, you’ve come to the right place. Register with us today by completing the form provided. We look forward to supporting you in your pet’s care and helping them live a happier, healthier life!

Owner Information

Name *

Name

First

Last

Address *

Address

City

State/Province

Zip/Postal

Primary Phone Number *

Email *

Cell Phone

Work Phone

Employer

Occupation

Co-Owner's Name

First

Last

Co-Owner's Phone

Do you authorize this person to make urgent treatment decisions if you are unavailable? *

Yes

Patient Information

Pet's Name *

Canine or Feline? *

Age *

Sex *

Male

Female

Breed *

Color *

Is your pet spayed/neutered? *

Yes

Weight

Additional Information

Referring Veterinarian/Hospital *

Phone *

Drug Allergies / Reactions *

Are all vaccinations current? *

Yes

Reason for Visit and Special Needs or Concerns *

Do you give permission for VSC to post pictures of your pet on our social media accounts? *

Yes

PAYMENT IN FULL IS REQUIRED WHEN SERVICES ARE RENDERED. Methods of payment include: cash, credit/debit card, and Care Credit.

Authorization: I am the owner of the above pet, or am acting as an agent for the owner, I accept full financial responsibility for professional and clinic fees. I give permission to release my pet's medical information to my referring or primary veterinarian.

Signature *