Registration Form Client InformationPreferred Method of Payment Cash Credit Debit CareCredit Scratch-Pay NO CHECKS ACCEPTEDOwner*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Owner Date of Birth* Date Format: MM slash DD slash YYYY Secondary OwnerPhoneEmergency Contact NameEmergency PhoneReason for visitHow did you learn about our clinic?Sign OutsideWebsiteFacebookInstagramPet InformationRegular Veterinarian Hospital Name*Name of Pet*Species*DogCatBreedColor/PatternBirthdate/Age*Sex*MaleMane NeuteredFemaleFemale SpayedUndeterminedSocial Media ConsentI 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 AgreeI do NOT give EPHR permission to use mine or my pet’s information and/or photo.AuthorizationI 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* Date Format: MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged.