Henrietta Animal Hospital, PLLC
Client Registration

Today’s Date _____________________
Driver’s License or ID Card Number: ______________ Expiration date: _______  
Name: ____________________________________________________
             (Last)                                      (First)                          (Middle)
Referred by: _______________________________________________
Address:  ____________________________________________________________________
                  (Street Number and Name)                        (City)               (State)            (Zip)
Occupation: _____________________________
Employer: __________________________________________________
                  (Name)
                  __________________________________________________
                  (Address)                               (City)               (State)            (Zip)
Telephone Numbers (please include area code): ___________________
Email: _____________________________________________________
Home: (___) ________            Work: (___) _________            Cell: (___) _______
Home Fax: (___) _______              Work Fax: (___) ________            Pager: (___)_______
Alternate Contact:____________________________________________________            
                               (Name)                                                                           (Phone)
[  ] Spouse   [  ] Partner   [  ] Co-owner  Name: ___________________________
                                                                              (Last)              (First)         (Middle)
Address: ________________________________________________________
                (Street number and name if different than above) (City)   (State)   (Zip)
Occupation: ______________________________________________________
Employer: _______________________________________________________
                  (Name
                  _________________________________________________________________
                   (Address)                                           (City)               (State)            (Zip)
Telephone Numbers (please include area code): ___________________
Email: _____________________________________________________
Home: (___) ________            Work: (___) _________            Cell: (___) _______
Home Fax: (___) _______              Work Fax: (___) ________            Pager: (___)___

PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE PERFORMED 

• In admitting my pet(s) for diagnostics, treatment, or surgery, I authorize the veterinarians of Henrietta Animal Hospital and their support staff to administer such treatment and/or perform such diagnostic or surgical procedures as deemed necessary.
• It is understood that an estimate of charges will be given for services.  No guarantee or assurance can be made as to the results that may be obtained.
• Further, I understand that a deposit of 50% is required before services are performed and I assume full financial responsibility for all charges incurred by my pet.  I realize that these charges may exceed a given estimate if complications arise.  I understand that I will be contacted prior to treatment, if possible, should complications occur.

Signature: _____________________________________________________