Name *

First

Last

Significant Other

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Phone Type: *

Work
Cell
Spouse
Home

Secondary Phone

Secondary Phone Type:

Work
Cell
Spouse
Home

Email Address *

Driver's License: *

(DEA Required for controlled drugs)

Owner's Date of Birth *

Referral Information

How did you find our practice?

Referred by a Friend:

(Who can we thank for the referral?)

Patient Information

Do you have a primary veterinarian?

Yes
No

I give my authorization to Universal Pet Hospital to take photos of my pet(s) for social media pages. *

Yes
No

Do you have proof of previous or current vaccinations with you? *

Yes
No

Are there any behavioral issues we should be aware of? If yes, what? *

Yes
No

What behavioral issues we should be aware of?

Do you have pet insurance? *

Yes
No

FINANCIAL POLICY

Payment is due as services are rendered. For hospitalized cases, an 80% deposit is required in advance. The balance is due upon discharge from the hospital.

We accept the following forms of payment: Cash, Credit Card, Apple Pay, and Scratch Pay

I understand that FULL PAYMENT OF ALL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED TO MY PET and I shall take full responsibility for payment of all charges related to the care of my pet prior to leaving the clinic or when services have been completed.

As indicated by my signature, I have read and acknowledged all information provided to me on this Registration Form and verify the information I have provided is correct.

Client Signature:

Clear Signature

Date:

Universal Pet Hospital

New Client Form

New Client Form at Universal Pet Hospital

Referral Information

Patient Information

FINANCIAL POLICY

We Proudly Serve the Pets of Palo Alto, CA, and Beyond.

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Location

Contact Information

Hours