Companion Animal Hospital

3720 Highway 431 North
Phenix City, AL 36867

(334)297-2316

companionanimalhospital.vet

 

NEW CLIENT FORM

If you would like to make an appointment, please complete this form. We look forward to meeting you and your pets!

After sending this form, please remember to complete a Pet Health History Form for each pet.

New Client

Name (required)
First Name (required)
Last Name (required)
Spouse/Significant Other Name
First Name
Last Name
Residence Address and Post Office Box (if used) (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Cell Phone (required)
Phone TypePhone Number (required)
Work Phone (required)
Phone TypePhone Number (required)
E-Mail Address (will not be shared!) (required) :
Wednesday is military appreciation day ~ 10% off treatments that day, after verification
Active Duty
Retired
Non Military


Emergency Contact (required)
First Name (required)
Last Name (required)
Emergency Contact's Phone (required)
Phone TypePhone Number (required)
I authorize CAH to use my email address for: email reminders, Pet Portal and pet health information. (required)
Yes
No


I hereby grant CAH permission to use my family and pet's photo(s) on its website and publications. (required)
Yes
No


Name and location of Former Veterinary Practice

May we request a transfer of your pets medical records?
Yes
No


We will do our best to accommodate your busy schedule. Request an appointment today!
Yes
No
I will call you


Anything else you would like for us to know?

How did you hear of our practice?
Sign
Yellow Pages
Internet
Other


If you heard of us by personal recommendation - Whom may we thank?

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 Companion Animal Hospital and that charges are due and payable at the time of service and a deposit is required for some medical and surgical treatments. We accept Cash, Check, MasterCard, Visa, Discover and CareCredit.
I have read this statement and - (required)
I Agree
I Disagree



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