Registration Form in Redlands, CA | Emergency Pet Hospital of Redlands

Client Information

Preferred Method of Payment

Cash
Credit
Debit
CareCredit
Scratch-Pay

NO CHECKS ACCEPTED

Owner*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Owner Date of Birth*

Secondary Owner

Phone

Emergency Contact Name

Emergency Phone

Reason for visit

How did you learn about our clinic?

Pet Information

Regular Veterinarian Hospital Name*

Name of Pet*

Species*

Dog
Cat

Breed

Color/Pattern

Birthdate/Age*

Sex*

Social Media Consent

I hereby give Emergency Pet Hospital of Redlands permission to take photographs and videos of my pet for purposes of posting to any/all social media accounts including, but not limited to Facebook, Twitter, Snapchat, Instagram, YouTube, and hospital websites associated with Valley Veterinary Care. I, hereby, release and discharge Valley Veterinary Care and all associated hospitals from any claims arising out of postings of photographs or videos.

I have read the social media consent and fully understand its contents. Valley Veterinary Care/EPHR has my permission to use*

My pet’s name
My pet’s name and My last name
My Pet’s name and My first/last name

Agreement*

I Agree
I do NOT give EPHR permission to use mine or my pet’s information and/or photo.

Authorization

I certify that I fully understand the contents of this form and am at least 18 years of age or older in order to make decisions and receive treatment for my pet.

I give Emergency Pet Hospital of Redlands permission to perform my pet’s initial physical examination and assessment prior to treatment and agree to pay the $110 emergency consultation fee upon check-in.

Signature of Owner*

Date*

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Email

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