New Clients

Thank you for considering our hospital as your pet’s provider of veterinary services. If you would like to move forward with scheduling an appointment, please fill out the form below. If you’d like some additional information on what to expect, please visit our new client page.

Client Information

Owner's First Name*

Owner's Last Name*

Primary Phone*

Email*

Address*

Street Address

Address Line 2

City

State

ZIP Code

Co-Owner's First Name

Co-Owner's Last Name

Co-Owner's Phone

Pet Information

Pet's Name*

Age*

If Known

Species*

Canine

Feline

Breed*

If Known

Color*

Microchip ID*

Yes

If yes, what is the ID number?*

Sex*

Intact Male

Neutered Male

Unaltered Female

Spayed Female

Special Diet

Previous Veterinary Hospital

Medical Conditions

Current Medications

Would you like to add a second pet?*

Yes

Pet 2 Information

Pet's Name*

Age*

If Known

Species*

Canine

Feline

Breed*

If Known

Color*

Microchip ID*

Yes

If yes, what is the ID number?*

Sex*

Intact Male

Neutered Male

Unaltered Female

Spayed Female

Special Diet

Previous Veterinary Hospital

Medical Conditions

Current Medications

Additional Information

How did you hear about us?*

If referral, please provide the full name of the individual who referred you*

Media Policy: Do you authorize BPAH to take pictures and/or videos of your pet for continuing education, medical publications, social media, and/or promotional purposes?*

Yes

I understand that the hospital staff will provide an estimate of current and anticipated charges any time I request one. By signing below, I am requesting that veterinary care be provided for pets presented by me or my agents. I understand that I am financially responsible for all services provided. Full payment is required at the time services are provided. We accept cash, Visa, Mastercard, Discover, American Express, and Care Credit.

Signature*

Date*

Name

This field is for validation purposes and should be left unchanged.

New Client Form

New Clients

Client Information

Pet Information

Pet 2 Information

Additional Information