New Client/Patient Registration Form

Slippery Rock Veterinary Hospital

131 Branchton Road
Slippery Rock, PA 16057

(724)794-8545

www.slipperyrockvet.com

Welcome! Our caring professionals look forward to treating your pet and to providing you with the service and attention you want. We are pleased to welcome you to our practice. So that we may better serve you -please take a few minutes to fill out this form as completely as you can. If you have any questions we are glad to help you. Thank you for involving us with your pets' healthcare needs.

New Client/Patient Registration

Your Information

Name (required)

First Name (required)	Last Name (required)

Address (required)
Street Address (required)

City (required) ,	State / Province (required)	Zip / Postal Code (required)

Phone (required)
Phone Type	Phone Number (required)

Phone (required)
Phone Type	Phone Number (required)

E-Mail Address (required) :

Occupation, Employer & Work Number

Other than yourself, who else can make medical/financial decisions for your pets? (required)

How did you FIRST hear of us? We greatly appreciate the referral of friends and family!

Yellow pages

Location

Road Sign

Internet

Website or Social Media

Referral by friend/family/other

If referred to us; please tell us whom we can thank for your visit?

Pet Information

Pet Name (required)

Describe your pet: (Dog/Cat; Breed; Colors; Date of Birth/Age; Male/Female; Neutered?; Microchip?) (required)

Describe another pet:(Dog/Cat; Breed; Colors; Date of Birth/Age; Male/Female; Neutered?; Microchip?)

Reason for appointment/visit? (required)

All fees are due at the time of service. Please indicate your preferred method of payment:

Cash

Check (photo id required; Returned checks- $50 service fee applies)

Credit Card: Visa, Mastercard, Discover, American Express

CareCredit Card

Please bring your pet's medical records or tell us where they are available below:

Hospital or Doctor Contact Information for medical records:

For your pet's exam with us - please bring a fresh stool and urine sample! See you soon!!

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Slippery Rock Veterinary Hospital

131 Branchton Road
Slippery Rock, PA 16057

724-794-8545

Modified Hours

Mon - Thurs 8am-4pm

New Faces & Paws Welcome!

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