New Patient Registration Form

Thank you for giving Centennial Animal Hospital the opportunity to care for your
pet(s). To ensure the best care possible, please fill out this form completely.

Owner's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Which number is best to reach you? *

Home
Cell

Can you receive text messages? *

Yes
No

Email *

Add a Co-Owner? *

Yes
No

Previous Vet:

Whom should we thank for referring you?

Pet's Name *

Sex *

Male
Female

Neutered/Spayed? *

Yes
No

Breed *

Color *

Birthdate or Age *

Current Medications

Please bring and give any medical records/vaccine records to the receptionists to make copies.

Diet *

I hereby authorize the veterinarian to examine, prescribe for, or treat the pet described above. I assume responsibility for all charges incurred in the care of this animal. I also understand that those charges will be paid in full at the time of release and that a deposit may be required for surgical treatment. Unpaid balances are subject to collection costs including late payment fees, court costs and attorney’s fees. *

I have read and agree.

Do we have your permission to share your pet’s image and story on our social media, website, and other forms of related media? Your name and personal information will never be shared. *

Yes
No

I authorize my emergency contact (other than myself or co-owner) to pursue treatment if I am unavailable. Your emergency contact must be an adult over the age of 18. *