GVH New Client Registration

Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together. Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.

IMPORTANT CHANGE IN HOSPITAL PROCEDURE

As of 1/20/21 we are offering CURBSIDE ONLY services. A veterinary nurse will bring your pet to and from your vehicle and you will be able to speak with the doctor by phone about the exam.

Owner Information

Primary Owner's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Mailing Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Primary Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

This will be the main phone number used to contact you. If this is a cell phone number, you will receive text reminders for appointments. You can opt out if you wish not to receive them.

Email Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

All email communications will be sent here, such as receipts, health service reminders and appointment reminders.

Driver's Licence Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

This will ONLY be needed if you intend to pay with a check.

Date of scheduled upcoming appointment, if any. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Co-owner's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Co-owner's Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Do you have a prefered doctor? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Is there anyone we can thank that referred you to us? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Authorization and Releases

I hereby authorize the veterinarian to examine, prescribe for, or treat my pet(s). I understand that these charges must be paid in full at the time of release and a deposit may be required for hospitalization and surgical treatment. An estimate will be provided, upon request, prior to treatment, for approval.

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Today's Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Release of Medical Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Do you authorize the release of vaccine and medical information to groomers and boarding facilities of your choice?

Photo Release {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Do you authorize the staff of this hospital to photograph your pet in pleasant scenarios and use the photos on the hospital's social media outlets, including Facebook, Instagram and Twitter? (Special permission would be obtained for photos of your pet during surgery, dental procedures, wearing a muzzle or any other kind of photo where your pet wasn't apparently happy.)

Please use this area to give us any other relevant information about yourself or your family {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Pet Information

1st Pet's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Breed {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Color {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date of Birth/Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Microchip Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date of last vaccines {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

If exact date is unknown, give an approximate date.

Previous Veterinary Practice {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Can we contact them on your behalf to request vaccines and medical history? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Please list any medications or supplements your pet takes. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

List any allergies or reactions your pet has. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Describe any past or current medical conditions your pet has had or has. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Please tell us anything else you'd like us to know about your pet. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Pet Information

2nd Pet's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Breed {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Color {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date of Birth/Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Microchip Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date of last vaccines {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

If exact date is unknown, give an approximate date.

Previous Veterinary Practice {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Can we contact them on your behalf to request vaccines and medical history? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Please list any medications or supplements your pet takes. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

List any allergies or reactions your pet has. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Describe any past or current medical conditions your pet has had or has. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Please tell us anything else you'd like us to know about your pet. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Pet Information

3rd Pet's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Breed {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Color {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date of Birth/Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Microchip Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date of last vaccines {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

If exact date is unknown, give an approximate date.

Previous Veterinary Practice {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Can we contact them on your behalf to request vaccines and medical history? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Please list any medications or supplements your pet takes. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

List any allergies or reactions your pet has. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Describe any past or current medical conditions your pet has had or has. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Please tell us anything else you'd like us to know about your pet. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Pet Insurance

With which company is your pet or pets insured? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

What is the policy number? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

If you do not yet have pet insurance but would like more information, please go to our website! https://gtvet.com/pet-health-insurance/ We give you the names of a few companies some of the staff and our clients use. You'll also find links with coverage questions and a comparison chart to help you make the best decision for your family. Please let us know if you have any questions!

Previous Vaccine and Medical Records

PLEASE READ CAREFULLY:

If your pet's previous vaccine or medical records are at one of these 3 places, we will need your help obtaining the information.

Banfield Pet Hospital - they will not release records to us unless you call and give your permission. The fastest way to get us your pet's records is for you to call and ask them to email the records to us at recep@gtvet.com.
Emancipet - you will need to sign a release form on their website before we can obtain records.
Dr. Tarleton at Austin Ave. Animal Hospital - Dr. Tarelton keeps paper records and does not have access to email or a fax machine. You will need to bring your records in for us to copy.

GVH New Client Registration

IMPORTANT CHANGE IN HOSPITAL PROCEDURE

As of 1/20/21 we are offering CURBSIDE ONLY services. A veterinary nurse will bring your pet to and from your vehicle and you will be able to speak with the doctor by phone about the exam.

Owner Information

Primary Owner's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Mailing Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Primary Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Driver's Licence Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of scheduled upcoming appointment, if any. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Co-owner's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Co-owner's Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you have a prefered doctor? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Is there anyone we can thank that referred you to us? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Authorization and Releases

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Today's Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Release of Medical Information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Photo Release {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please use this area to give us any other relevant information about yourself or your family {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Pet Information

1st Pet's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Breed {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Color {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of Birth/Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Microchip Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of last vaccines {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Previous Veterinary Practice {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Can we contact them on your behalf to request vaccines and medical history? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please list any medications or supplements your pet takes. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

List any allergies or reactions your pet has. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Describe any past or current medical conditions your pet has had or has. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Please tell us anything else you'd like us to know about your pet. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Pet Information

2nd Pet's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Breed {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Color {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of Birth/Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Microchip Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of last vaccines {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Previous Veterinary Practice {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Can we contact them on your behalf to request vaccines and medical history? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please list any medications or supplements your pet takes. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

List any allergies or reactions your pet has. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Describe any past or current medical conditions your pet has had or has. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Please tell us anything else you'd like us to know about your pet. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Pet Information

3rd Pet's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Breed {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Color {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of Birth/Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Microchip Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of last vaccines {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Previous Veterinary Practice {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Can we contact them on your behalf to request vaccines and medical history? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please list any medications or supplements your pet takes. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

List any allergies or reactions your pet has. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Describe any past or current medical conditions your pet has had or has. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Please tell us anything else you'd like us to know about your pet. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Pet Insurance

With which company is your pet or pets insured? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What is the policy number? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Previous Vaccine and Medical Records

PLEASE READ CAREFULLY:

If your pet's previous vaccine or medical records are at one of these 3 places, we will need your help obtaining the information.

Banfield Pet Hospital - they will not release records to us unless you call and give your permission. The fastest way to get us your pet's records is for you to call and ask them to email the records to us at recep@gtvet.com.
Emancipet - you will need to sign a release form on their website before we can obtain records.
Dr. Tarleton at Austin Ave. Animal Hospital - Dr. Tarelton keeps paper records and does not have access to email or a fax machine. You will need to bring your records in for us to copy.