New Client Registration

Thank you for considering Gause Boulevard Veterinary Hospital for your pet’s needs. Please fill out our new Client/Patient registration in its entirety to ensure we can provide you and your pet with the best possible care.

OWNER INFORMATION

Today's Date

Have you ever been to Gause Boulevard Veterinary Hospital before?YesNo

Your First Name: *

Your Last Name: *

Email: *

Main Contact Number: *

Secondary Contact Number: *

Street Address *

City *

State/Province *

ZIP / Postal Code *

Preferred Contact Method:CallTextEmail

Preferred Contact Number:PrimarySecondary

How did you hear about us?Google (or other search engine)Social MediaOther

If referred by:Referred by:

Employer's Name:

IS THERE A SPOUSE/PARTNER/FAMILY MEMBER WHO SHOULD BE LISTED ON YOUR ACCOUNT?

Name:

Contact Number:

Relationship:

IN CASE OF EMERGENCY

Is there anyone else (beside above listed contacts) who should be listed on your account, who has ongoing permissions to make medical decisions for your pet(s)? YesNo

If YES, whom shall we contact:

Contact Number:

Relationship:

PET #1 INFORMATION

Pet's Name: *

Date of Birth: *

Age: *

Species:

What is the sex of your pet? *MaleNeutered MaleFemaleSpayed Female

Is your pet microchipped? *YesNoUnsure

Microchip Number (If known)

Breed: *(IF YOUR CAT IS NOT A KNOWN BREED, DO THEY HAVE LONG, MEDIUM OR SHORT HAIR?)

Color:

Primary reason for your visit to GBVH?

Previous Veterinarian:

Can we call for your Pet's Medical Records?YesNo

Does your Pet currently have a Pet Insurance Policy?YesNo

If YES, what company is your Policy through?

PET #2 INFORMATION

Pet's Name:

Date of Birth:

Age:

Species:

What is the sex of your pet?MaleNeutered MaleFemaleSpayed Female

Is your pet microchipped?YesNoUnsure

Microchip Number (If known)

Breed:(IF YOUR CAT IS NOT A KNOWN BREED, DO THEY HAVE LONG, MEDIUM OR SHORT HAIR?)

Color:

Primary reason for your visit to GBVH?

Previous Veterinarian:

Can we call for your Pet's Medical Records?YesNo

Does your Pet currently have a Pet Insurance Policy?YesNo

If YES, what company is your Policy through?

CLIENT POLICIES AND PROCEDURES

We love Social Media! Do we have your permission to post pictures and/or videos of your pet(s) and our team on Facebook, Instagram, Twitter, TikTok, www.gauseblvdvet.com and any other marketing and/or social media outlets we may choose?YesNo

Gause Boulevard Veterinary Hospital uses email, text and our own hospital app for communications regarding our patient’s reminders for health care needs. Do we have permission to contact you via email, text and/or our app regarding these reminders?YesNo

If I neglect to pick up my pet within 10 days of the pickup date and fail to make other arrangements, GBVH assumes that the pet is abandoned and is hereby authorized to take possession of the pet and make any decisions as may be deemed best and necessary for its care.

INITIALS REQUIRED:

We use an AI Scribing platform that records audio throughout your visit with our staff to help better document your pet's entire visit with us. Do you give us permission to audio record your visit?YesNo

FINANCIAL POLICIES

We do NOT bill. All fees are due at the time services are rendered.
We accept Paypal, Venmo, Visa, MasterCard, Discover and American Express as well as cash.
We do NOT accept checks.
As a courtesy we do offer extended payment plans through the following outside sources: Care Credit, Scratch Pay, Cherry, and PayPal Financing.

INITIALS REQUIRED:

Signature

Today's Date:

!Side Menu Images

!Mobile Content

!Header Logo

!Give us a call button

!Call Icon