Client Registration Form

Please fill in our form below, and download it if you'd like to print it out.
Download the Form
Owner's Name:
DOB (mm/dd/yyyy):
Enter you phone number:
Phone type?
Email Address:
Best Method of Contact:
How did you find out about our hospital? (Check all that apply.)
If from a referral, who may we thank?
If from a website, please specify what site?
Photo Consent: We love social media! Do we have your permission to share your pet’s image and story on social media, our website & other forms of related media? Your name and personal information will never be shared.
Boarding Facility: I routinely use the boarding facility listed below for my pet(s).I give permission to MVAH to release any relevant medical information to the boarding facility if necessary.
Facility Name:
Facility Phone Number:
Consent for Emergencies/Release of Medical Information: I give permission for the individuals named below to obtain medical information for my pet(s) and to seek emergency treatment for my pet(s) in the event that I am unable to do so. I understand that, as the owner, I am financially responsible for any and all services rendered.
Inidividual #1 Name:
Inidividual #1 Phone Number:
Inidividual #2 Name:
Inidividual #2 Phone Number:
Terms of Service: PAYMENT IN FULL is required at the time services are rendered. We accept cash, checks, Visa, MasterCard, Discover and Care Credit as forms of payment.
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(585) 624-2240