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New Client Registration Form
Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.
Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.
Owner's Name
Name
*
First
Last
Phone
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Email
*
Enter Email
Confirm Email
Co-Owner's Name & Contact #
Name
First
Last
Phone
How did you find out about our practice?
*
Google
Hoffman Animal Hospital Website
Facebook
Open House
SPCA
SPCA Walk
Community Event
Strawberry Festival
Cape Fun Run
Referral Vet
Drove By
Friend
Other
If Personal Referral, is there someone we can thank for this referral?
Name of previous Veterinarian
First
Last
Phone number of previous Veterinarian
Pet Information
Pet's Name
*
Species
*
Dog
Cat
Rabbit
Ferret
Bird
Reptile
or if other species
Breed (if known)
Color
Date of Birth or Age (if known)
Special Identification (tattoo, microchip, etc.)
Sex
*
Neutered Male
Spayed Female
Male
Female
Unknown
I agree to allow Hoffman Animal Hospital to release portions of my pet(s) medical history and record, including personal recollections, radiographs, photographs, videotape images, or other images to the below media entities on social media, blogs, marketing materials, and educational information.
*
Yes
No
Other Pets:
Any previous serious illness or surgeries?
Any allergies to vaccinations or medications?
Is your pet on any special diets or medications?
Would you like to be present during treatment of your pet?
Yes
No
All fees are due at the time services are rendered and I agree to pay the balance in full. If not paid in full, I agree to pay all costs associated with collection. I agree and understand that by typing my name below, all electronic signatures are the legal equivalent of my signature and I consent to be legally bound to this agreement.
Name
*
First
Last
Δ
New Clients
What to Expect
Online Forms
New Client Special
About Us
Our Veterinarians
Hospital Policies
Community Involvement
Fear Free Visits
Careers
Services
Boarding & Daycare
Wellness Exams
Surgery
Spay & Neuter
Dentistry
Microchipping
Diagnostics & Lab
Health Certificates
Wellness Plans
Resources
Veteran Service Dog Program
Pet Health Library
How-To Videos
Pet Health Checker
News
Veterinary Resources
Pet Insurance Estimator
Local News and Events
Canine Influenza Virus (CIV)
Canine Blood Bank Donor Site
Contact
Emergencies
Online Pharmacy
Client Portal