New to Craig Road Animal Hospital?

Craig Road Animal Hospital
New Client Registration Options

WELCOME! To expedite your first visit and the time associated with creating your account, we've enabled these
options to print our New Client Registration Form, complete at your leisure, and bring with you to the hospital; or registering online. We look forward to meeting you and your pet(s)!

1)	Download/view Adobe PDF file (print and fill out) (PC users, right-click to download, left-click to view through browser; Mac users, control-click to download)
2)	Browser-printable form (2 pages)

3) Online registration -- We've enabled this online registration feature for new clients. Note that use of this feature does not schedule an appointment. Your application will be processed within 24 hours. You will contacted by telephone to confirm that your online registration has been completed and have the opportunity to schedule an appointment. Please complete and submit the online form below. You will need to have your pet's vaccination records and medical history handy.

Please use the TAB key or your mouse to move between fields, not the "ENTER" key. "ENTER" will submit this form prematurely.

Personal Information

Owner's First Name	Last name

Spouse/Other	Last Name

Drivers License Number: (required for check payments)	Issuing State:	Expiration:
Street Address/P.O. Box	Unit/Apt.
City, State, Zip+4:

Home Phone:
Work Phone:
Cell Phone:
E-mail Address:

Employer:
Employer Address:
City, State, Zip+4:

In case of emergency, call (name) at (number)

How did you hear about our hospital? (check all that apply)

Hospital Sign Yellow Pages American Animal Hospital Association

Animal Foundation Dewey Animal Shelter

Individual - Someone we may thank:

Other - Please specify:

Previous animal hospital/veterinarian information

Name of clinic or doctor:
City/State:

May we request your pet's health records? Yes No

Animal Medical History (complete one column for each pet, as completely as possible)

Pet Information

1st Pet

2nd Pet

3rd Pet

Name:

Species (dog, cat, reptile, bird, etc.):

Breed:

Description/Color(s):

Date of Birth:

Sex:
(Female, Male,
Female/Spayed,
Male/Neutered)

F/S

M/N

F/S

M/N

F/S

M/N

Length of time owned:

Diet (type of pet food):

Please provide dates of most recent shots (mm/dd/yy)
Vaccination History		1st Pet	2nd Pet	3rd Pet
Dogs	Distemper:
Rabies:
Parvo Virus:
Corona Virus:
Bordatella: (kennel cough)
Lyme:
Cats	ENT-FVRC (Feline Distemper)
Rabies
FeLV (Feline Leukemia)
FIP (Feline Infectious Peritonitis)

Previous Medical History	Pet 1	Pet 2	Pet 3
Current Special Diet?
Currently on Medication? Type?
Prior Illness?
Prior Surgery?
Prior Urinary Problem?

Any other information you feel we should know about your pet?

ALL FEES ARE DUE AT THE TIME THE PATIENT IS RELEASED
Upon your request, we will be happy to provide you with a written estimate of fees for any treatment,
emergency care, surgery, or hospitalization. A deposit may be required prior to some procedures/treatment.

Submitting this electronic form indicates your intent to secure the services of Craig Road Animal
Hospital and for us to proceed with the creation of an account for you in our system. Craig Road Animal
Hospital is not responsible in the unlikely occurrence of a technical error when submitting this form, errors or
misinformation entered by the submitter, and other circumstances beyond the hospital's control. All personal
information submitted is confidential and for internal use according to hospital policies and to the extent
allowed by applicable government, consumer, and financial regulations.

I have read the notice above and accept these terms

I do not accept this the terms of this notice - take me back to the Main Page (your entries will not be saved)

If you have filled-in the fields above as completely as possible, click the "Submit" button below.
(just once, please -- it may take a few seconds to process)