Companion Animal Hospital

3720 Highway 431 North
Phenix City, AL 36867

(334)297-2316

www.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)
Spouse/Significant Other Cell Phone
Phone TypePhone Number
Spouse/Significant Other Work Phone
Phone TypePhone Number
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


I assume responsibility for all charges incurred in the care of my animals. I also understand that all fees will be paid at the time of release and that a deposit is required for some medical and surgical treatments.
Payment methods accepted: Cash | Check | Mastercard | Visa | Discover | American Express | Care Credit | ScratchPay

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?

By completion of this form, I agree that all of the above information is current and accurate. I understand that selecting "I agree" below qualifies as my digital signature. (required)

I Agree
I Disagree



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