New Client RegistrationNew Client Registration Step 1 of 250%Client InformationPlease complete all required fields.Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Your Date of Birth (Required For Some Medications)(Required) MM slash DD slash YYYY Email(Required) By providing your email address, you are agreeing to receive emails regarding your pet's health, medical reminders and news about Northtown Guardian Pet Hospital. You can opt out at any time.Primary Phone(Required)Secondary PhoneSpouse/Partner Name First Last Spouse/Partner PhoneDo you have insurance for your pet? Yes NoInsurance Provider InformationHow did you find us?(Required) Internet Search Social Media Yelp Word of Mouth/Referral OtherWho referred you so we can thank them?Pet InformationPlease complete all required fields.1st Pets Name(Required)Date of Birth (or approximate)(Required) MM slash DD slash YYYY Sex(Required) Male Neutered Male Female Spayed FemaleSpecies(Required) Dog Cat OtherIf you have previous veterinary records for this pet, please upload them here.Max. file size: 32 MB.Does this pet have records from another veterinary hospital that need to be transferred? Yes NoOther veterinarian that may have records for the patient:What is the hospital's name, city and state?Is there any information you would like to share with our staff regarding this pet (i.e. allergies, medical problems, behavior issues, etc.)?Do you have a second pet to provide information for?(Required) Yes NoSecond Pet InformationPlease complete all required fields.Second Pet's Name(Required)Date of Birth (or approximate)(Required) MM slash DD slash YYYY Sex(Required) Male Neutered Male Female Spayed FemaleSpecies(Required) Dog Cat OtherIf you have previous veterinary records for this pet, please upload them here.Max. file size: 32 MB.Does this pet have records from another veterinary hospital that need to be transferred? Yes NoWhat is the hospital's name, city and state?Is there any information you would like to share with our staff regarding this pet (i.e. allergies, medical problems, behavior issues, etc.)?Do you have a third pet to provide information for?(Required) Yes NoThird Pet's InformationPlease complete all required fields.3rd Pet Name(Required)Date of Birth (or approximate)(Required) MM slash DD slash YYYY Sex(Required) Male Neutered Male Female Spayed FemaleSpecies(Required) Dog Cat OtherIf you have previous veterinary records for this pet, please upload them here.Max. file size: 32 MB.Does this pet have records from another veterinary hospital that need to be transferred? Yes NoWhat is the hospital's name, city and state?Is there any information you would like to share with our staff regarding this pet (i.e. allergies, medical problems, behavior issues, etc.)?Policies & ConsentSocial Media Agreement: Northtown Guardian Pet Hospital occasionally features client pets on our social media accounts. By opting in, you give your consent for your pet(s) to be featured. We will never post medical or case photos or information without additional consent from you.Social Media Consent Yes, I have read the above statement and give NGPH my consent. No, I do not consent.Financial Policy: Payment is due in full at the time that services are rendered or performed. We do not bill or invoice for services. In-patient care is by written consent. We accept cash, check, Visa, Mastercard, Discover, and American Express payments. We do not extend credit. We also accept CareCredit (www.carecredit.com). All open invoices are sent to collections after 45-days. All insurance is third-party, and we do not prepare claims in house. We will send medical records to insurance companies by request. Any information that we collect is private and for our use only.Late Policy: We strongly believe in providing our clients and their pets the full attention and time with the doctors that they deserve. As such, if you are 10-minutes or more late to your appointment, your appointment will be forfeit and canceled. Depending on the capacity of our hospital, your appointment may be subject to rescheduling or indefinite postponing if no available new client appointments are available.Cancellation Policy: We understand that life sometimes gets in the way and you can't always make your scheduled appointment. To help us out, it is important for clients to give the hospital at least 24-hours notice prior to cancelling or rescheduling an appointment. Doing so ensures that we can make time available for another pet in need.Policy Agreement(Required) By checking this box, I indicate that as the owner of this pet(s), I understand and agree to Northtown Guardian Pet Hospital's Financial, Late and Cancellation Policies.PhoneΔ
