(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. We are not currently taking on new clients but will keep your information on file until a time we are ready to begin accepting new patients and clients again.
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
Your Name
*
First
Last
Preferred Pronouns
She/Her
He/Him
They/Them
Other - Please let us know!
Driver's License No.
Must be confirmed by a staff member
Partner/Spouse Name
First
Last
Preferred Pronouns
She/Her
He/Him
They/Them
Other - Please let us know!
Driver's License No.
Must be confirmed by a staff member
Mailing Address
*
Street Address
Address Line 2
City
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District of Columbia
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Armed Forces Americas
Armed Forces Europe
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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?
Yellow Pages
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
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
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
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
Authorization
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
Date
*
Date Format: MM slash DD slash YYYY
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
Online Pharmacy
Contact
Pet Health Questionnaire