Step 1 of 3 33% Owner Name* Phone Number* Email Address* Your Birthday* MM slash DD slash YYYY 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 Name Alternate Contact Phone Number Alternate Contact Email How 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 appointments We 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 All payments are due at the time of services rendered. We accept all major credit cards. Payment plans for Scratch Pay & Care Credit can be approved in as little as 10 minutes and are subject to limitations. I have read and understand the above statements and agree to all terms therein.Type Signature PhoneThis field is for validation purposes and should be left unchanged.
