Step 1 of 3 33% Owner Name*Phone Number*Email Address*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Alternate Contact NameAlternate Contact Phone NumberAlternate Contact EmailHow did you hear about us?* First PetSelect One:* Dog Cat Pet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PParvoCoronaBordatella Date of VaccinationsRabiesFELVENT-FVRCPFIP Second PetSelect One: Dog Cat Pet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PParvoCoronaBordatella Date of VaccinationsRabiesFELVENT-FVRCPFIP Third PetSelect One: Dog Cat Pet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PParvoCoronaBordatella Date of VaccinationsRabiesFELVENT-FVRCPFIP May we contact your previous veterinarian for records? Yes No Previous veterinarian- we require previous records 24 hours in advance to new client appointmentsWe authorize Kensington Veterinary Hospital and its representatives and employees the right to take photographs of me and/or my pet, and to copyright, and use/publish for any lawful purpose, including web content and advertising.* Yes No Cancellation Policy 24 hours notice required for all cancellations. A $65 fee will be charged for late cancel/no show appointments or 50% of the total estimated cost for dental/ surgery cancellations. Payments Payment is required in full at the time of service. Although we do not offer payment plans, we recommend Care Credit for clients needing an extended payment period (Carecredit.com). Due to the escalating costs of merchant service fees, payments made using a credit card (Visa, Mastercard, Discover, Care Credit and American Express) will incur an additional 1.75% fee to you. Payments by check, cash and debit card (using pin) do not incur an additional fee. I have read and understand the above statements and agree to all terms therein.Type SignaturePhoneThis field is for validation purposes and should be left unchanged.
