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(802) 879 6311
129 Main St, Essex Junction, Vermont 05452
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New Client Registration Form
New clients are welcome to register to our veterinary practice in Essex Junction, Vermont.
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 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.
Date
*
Date Format: MM slash DD slash YYYY
Have you already scheduled your appointment with us?
*
Yes
No
If yes, please indicate the date of your scheduled appointment
Date Format: MM slash DD slash YYYY
If no, please contact us at 802-879-6311 and one of our team members would be happy to help you schedule your appointment!
Your Name
*
First
Last
Preferred Pronouns
She/Her
He/Him
They/Them
Other - Please let us know!
Partner/Spouse Name
First
Last
Preferred Pronouns
She/Her
He/Him
They/Them
Other - Please let us know!
Mailing Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
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New Hampshire
New Jersey
New Mexico
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North Carolina
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Phone
*
Work Phone
Your Cell Phone
*
Partner's Cell
Emergency Contact:
Phone
Email Address
*
used for reminders and as alternate contact method only. Please write DECLINE if you do not wish to provide an email address
Enter Email
Confirm Email
Other Individuals authorized to seek treatment for your animals (must be 18 years or older)
How did you learn of our clinic?
*
Clinic Sign
Clinic Location
Personal Referral
Internet Search / Website
Newspaper / Print Media
If Personal Referral, is there someone we can thank for this referral?
Animal #1
Pet's Name
Pet's Nick Name
Species
Cat
Dog
Breed
Description (Color)
Age or Date of Birth
Sex/Neutered or Spayed
Medications/supplements?
What kind of pet food?
Known Allergies?
Indoor/ Outdoor?
Prior Illness
Prior Surgery
Medical Records Upload
Please upload any previous medical records. Medical records may also be emailed directly from your previous veterinarians office to us at contact@vtvet.com.
Drop files here or
Accepted file types: jpg, gif, png, pdf.
Input information for a second pet?
Yes
No
Animal #2
Pet's Name
Species
Cat
Dog
Breed
Description (Color)
Age or Date of Birth
Sex/Neutered or Spayed
Medications/supplements?
What kind of pet food?
Known Allergies?
Indoor/ Outdoor?
Prior Illness
Prior Surgery
Medical Records Upload
Please upload any previous medical records. Medical records may also be emailed directly from your previous veterinarians office to us at contact@vtvet.com.
Drop files here or
Accepted file types: jpg, gif, png, pdf.
Input information for a third pet?
Yes
No
Animal #3
Pet’s Name
Species
Cat
Dog
Breed
Description (Color)
Age or Date of Birth
Sex/ Neutered or Spayed
Medications/supplements?
What kind of pet food?
Known Allergies?
Indoor/ Outdoor?
Prior Illness
Prior Surgery
Medical Records Upload
Please upload any previous medical records. Medical records may also be emailed directly from your previous veterinarians office to us at contact@vtvet.com.
Drop files here or
Accepted file types: jpg, gif, png, pdf.
Authorization
Consent to release medical records
I authorize release of my pet's medical records to any boarding facility
I authorize release of my pet's medical records to any veterinary clinic
I authorize release of my pet's medical records to any pet insurance provider
Consent
I hereby authorize the veterinarian to examine, prescribe for, or test the above describes pet(s). I assume responsibility for all charges incurred in the care of this animal. All professional fees are due at the time services are rendered. In the case of extensive medical or surgical procedures an advance deposit maybe required. There will be a service charge for any returned checks. I hereby grant Mountain View Animal Hospital the right to use a photograph of my pet in connection with its promotional materials in any and all media, including printed material, internet and film.
Name
*
First
Last
Δ
Home
New Clients
About
Meet Our Team
Take A Tour
Promotions
Careers
Services
Anesthesia and Patient Monitoring
Exotic Pet Medicine and Surgery
Health Certificates
Laser Therapy
Medical Services
Nutritional Counseling
Preventive Services
Surgical Services
Veterinary Dentistry
Wellness and Vaccination Programs
Additional Services
Pet Health
Pet Health Checker
Pet Health Library
Pet Food Recalls
Pet Insurance
Product Recalls
How-To Videos
News
Pet Portal
Pet Records
Refill Requests
Mobile App
Pharmacy
Online Pharmacy
Purina Vet Direct
Contact
Pet Health Questionnaire
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