Online Forms

South Bay Animal Hospital offers our patient form(s) online so you can complete it in the convenience of your own home or office.

Registration Form


South Bay Animal Hospital & Pet Resort
Registration Form

Today’s date:

Client Folder Number:


CLIENT INFORMATION

Client’s Name:

Prefix:

Preferred Phone Number:

Is this your legal name?

If not, what is your legal name?

Home phone no.:

Birth date:

Street address:

Cellular Phone no.:

Work phone no.:

P.O. box:

City:

State:

ZIP Code:

May we use pictures of you and/or your pet(s) on our social media?

E-mail:

Chose clinic because/Referred to clinic by (please check one box):


PATIENT INFORMATION
(Please give your insurance information to the receptionist if available.)

Patient Name:

Birth date:

Breed:

Color:

Is he/she micro-chipped?

Sex:

Neutered/ Spayed:

Current Diet:

Visit Type:

Please indicate insurance:

Subscriber’s name:

Policy no.:

Deductible:

Policy no.:

Vaccines Up To Date:

Last Vet Visit:

Previous Vet:


IN CASE OF EMERGENCY

Name of local friend or relative (not living at same address):

Relationship to client:

Home phone no.:

Cell phone no.:


The above information is true to the best of my knowledge. I understand that I am financially responsible for any balance. I also authorize South Bay Animal Hospital & Pet Resort to release any information required to process my claims. I assume responsibility for all charges incurred in the care of my pet(s). I understand that these charges must be paid at the time of release and that a deposit may be required for any surgical procedures, and/or hospitalization. I also understand that South Bay Animal Hospital & Pet Resort does not accept checks or billing. I also understand that no guarantee of successful treatment is made and release the doctors and agents of South Bay Animal Hospital & Pet Resort of any and all liability, and should a dispute arise, I will be financially responsible for any and all legal expenses incurred by both parties...

Owner/Agent signature:

Date:

NEW CLIENT?

SCHEDULE AN APPOINTMENT WITH US

Online appointments must be made between 8:00 am and 4:30 pm. Please call for appointments 24/7!
Emergency Only walk-in hours are between 8:00 pm and 8:00 am.


REQUEST AN APPOINTMENT NOW
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