SCAH Client Registration

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Swift Creek Animal Hospital
Client Registration Form

Have you already set up an appointment? Yes No
If so, date / approximate date:

Client Information:

Last Name:	First Name:
Spouse / Co-Owner Last name:	Spouse / Co-Owner First Name:
Address:	City:	Zip:
Home Phone:	Work Phone:	Cell / Other:
Employer:	Spouse / Co-Owner Employer:
E-Mail:	Referred By:
* The Information given above is for our personal records only, and will not be shared without your permission. Clients that wish withhold their social security number will have their account limited to cash or credit card only.

Patient Information:

Patient Name	Breed	Color	Birth Date or Age	Sex	Spayed or Neutered
A.				M F	Yes No
Medical Alerts:
B.				M F	Yes No
Medical Alerts:

Treatment Authorization and Payment Terms

I hereby authorize the veterinarian to examine, prescribe, and provide medical care of the patients described above. I certify that I am 18 years of age or older and the information given above to be accurate. I understand payment is expected at the time services are rendered, and that any unpaid balance is subject to 18% APR and a minimum finance charge of $5.00 per month.

Name: Date:

Virginia Veterinary Medical Staff Hours Disclosure

Swift Creek Animal Hospital’s normal business hours are as follows:
Monday - Thursday: 7:00am – 7:00pm; Friday 7:00am - 6:00pm
Saturday: 8am – 2pm

Swift Creek Animal Hospital will only be staffed during these hours and will not have continuous medical care other than these hours. I have read and understand the disclosure of medical staff hours listed above.