Rogers New Client Registration Form

Thank you for considering our hospital as your pet’s provider of veterinary services. Please complete our new client registration form below to expedite your first visit.

Owner's Name

Name(Required)
Email(Required)
Address(Required)

Co-owner's Name & Contact #

Name
How did you find out about our practice?

Emergency Contact

Emergency Contact Name

Pet Information

Address
Date of last vaccines (if known)
MM slash DD slash YYYY
Authorization & Digital Communication Consent

I authorize the hospital to release my pet’s medical information to other veterinary hospitals, groomers, and kennels, including my phone number if my lost pet is recovered. I acknowledge that conversations during my pet’s visit may be recorded for quality assurance and service improvement purposes. I hereby grant the hospital all rights, title, and interest in any photographs, images, videos, or audio recordings of my pet or myself taken during my pet’s visit. This includes the use of such materials for promotional purposes, on the hospital’s website, and other marketing materials. If the veterinary team determines that immediate treatment is necessary for the health and well-being of my pet, and I or my co-owner are unable to be reached, I consent to the administration of all reasonable treatments recommended. I assume responsibility for all charges incurred for my pet(s) and understand that payment is due at the time services are rendered.

I understand that the hospital offers various forms of digital communication to keep me informed about my pet’s health, remind me of upcoming appointments, and share promotions and health tips. By signing below, I authorize the hospital to contact me via email, phone, and/or text message (SMS). I understand that I can opt out of these communications at any time by following the unsubscribe instructions in any communication received.