New Client Registration Form

  • Client Information

  • MM slash DD slash YYYY
  • Spouse / Partner Information

    If applicable
  • MM slash DD slash YYYY
  • Pet Information

  • Owner’s Responsibility

  • Payment is required for all services at the time they are rendered unless prior arrangements have been made with hospital management. In the event that a refund is due and the original payment is a credit card, the refund will be posted against the original credit card. We accept credit card payments over the phone with prior approval. All returned checks are subject to a $25.00 service fee. A 90-day old account balance is subject for collection efforts and a $25.00 collection fee will be assessed. Your signature below signifies your understanding and willingness to comply with the hospital’s payment terms. In some cases, a deposit may be required before proceeding.

    Veterinary Consent: I authorize Erickson Veterinary Hospital to perform the treatment/procedure(s) described in my pet’s chart. I will be informed of the reasons for the treatment/procedure(s), along with the expected benefits and risks involved. I understand that unforeseen conditions may require an extension of a planned procedure and/or surgery. I hereby authorize the performance of such procedures or surgeries as are necessary and advisable in the professional judgment of EVH veterinarians or a relief veterinarian. I understand that I assume all risks and am responsible for all costs involved. I also authorize EVH to use pictures of my pet(s) for promotional purposes. Consent will apply to all future pets added to this account unless and until I provide a written revocation of that consent.