New Client Registration Form

Welcome to PURE! We are delighted to welcome new clients and their beloved pets to our practice. To streamline your first visit, we have created a comprehensive New Client Registration Form. This form allows us to gather essential information about you, your pet, and your preferences, ensuring we provide the best possible care from the moment you walk through our doors.

Please take a few moments to fill out the form below with details such as your contact information, your pet’s medical history, and any special requirements or preferences you may have. By completing this form ahead, you’ll help us serve you more efficiently and make your experience with us as smooth and enjoyable as possible.

Thank you for choosing PURE. We look forward to meeting you and your furry family member soon!

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Client Information:

Primary Contact Name *

First

Last

Email Address *

Phone Number *

Alternate Phone Number

Home Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

We use text messages and email to communicate information about your pet. If you would like to opt out of these reminders, please indicate below. *

• I consent to both text and email communications at the above primary number and email.
• I do not consent to both text and email communications at the above primary number and email.
• I consent to receive text messages only at the above primary number.
• I consent to receive email communications only at the above email address.

Do you have a secondary contact?

• No
• Yes

Name

First

Last

Email Address

Phone Number

Does the secondary contact’s Home Address differ from the primary contact’s?

• No
• Yes

Secondary Contact - Home Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Pet Information

Layout

Pet's Name *

Age

Species and Breed

Date of Birth (if known)

Color

SEX *Select SexIntact MaleNeutered MaleIntact FemaleSpayed Female

Special Identification (Tatoo, Microchip, Etc.)

In the event your pet has an immediate need for life saving measures

Authorize or decline CPR (Cardiopulmonary Resuscitation) *

• Yes
• No

Please specify above: YES or NO, in the event your pet has an immediate need for life-saving measures.

Pet Medical History

Do you have a Primary Veterinary Practice or Hospital? *

• Yes, I have a Primary Veterinarian
• Yes, I have a Primary Vet Hospital
• No, I do not have a Primary Vet Practice or Hospital.

Please provide the name of your Primary Veterinary Practice. *

Please provide the name of your Primary Veterinary Hospital *

Layout

Previous Veterinarian (if any)

Date of Last Vaccine (if known)

Vaccine History

List of previous vaccines received, (e.g., rabies, distemper, etc.).

Is your pet on any current medication(s) or supplement(s)? *

• Yes
• No

Please List the Medication or Supplement

What food does your pet eat? *

Does your pet have allergies or drug reactions? *

• Yes
• No

Please list the allergies and reactions

Are there any current or past medical conditions of which we should be aware? *

• Yes
• No

Please comment on the conditions and indicate if they are current or past conditions

Please use the following box to provide us with any other relevant information about your pet

Referral Information

How did you find out about our practice?

• Clinic Location
• Personal Referral
• Internet Search / Google /Website
• Yellow Pages
• Clinic Sign
• Advertisement / Online / Print Media
• Social Media (Facebook, Instagram)
• Referred by Vet
• Other

Which platform did you find us on? (e.g., Facebook, Instagram, Twitter, etc.)

Please specify the vet or veterinary clinic that referred you to us.

Please specify which Clinic Location you visited

Is there someone we can thank for this referral? Who referred you to our practice? Please provide their name and relationship to you.

Did you find us through an internet search, Google, or our website? Please specify.

Can you provide more details about the Yellow Pages listing you found us in?

Where did you see our clinic sign? Please provide the location and any additional details.

Which medium did you see our advertisement in? (e.g., newspaper, magazine, website) Please provide the name and date of the publication or website.

Please specify how you found out about our practice. Any additional details would be helpful.

Photo and Video Consent

Photograph and Video Release: There may be times we would like to share a photo of your pet with our social media sites (Including but not limited to our website, Facebook, Instagram, etc.) Please indicate your wishes below: I hereby grant PURE permission to use my pet(s) photograph or video. *

• Yes
• No

Terms and Conditions Acknowledgment: *

• I, the undersigned, am the owner or agent for the owner of the animal(s) described, and I have the full exclusive authority to execute this consent.

• I certify I am 18 years of age or older.
• I give permission to doctors, staff, authorized agents, or representatives of the hospital to examine, prescribe for, and treat my pet(s).
• I agree to pay for all services rendered and medications, goods, and supplies when purchased.
• I understand that all fees are due at the time services are rendered and the hospital accepts cash, Care Credit Scratchpay, Trupanion and all Major Credit cards. WE DO NOT ACCEPT CHECKS.
• I understand a deposit may be required for surgical or medical treatment.
• I release this hospital of any and all liabilities.

By my signature below, I hereby acknowledge that I agree to all of the above and acknowledge the receipt of a copy of this agreement upon request.

Owner/Agent Print Name *

Owner/Agent Signature *

Clear Signature

Submit