If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required We appreciate you taking the time to read over and fill out this registration form to ensure that our information on file is accurate and that you are familiar with our financial policy. Thank you for choosing Pembroke Animal Hospital! First Name * Last Name * Owner Date of Birth * Co-Owner (spouse, family member, etc.) Co-owner Date of Birth Address 1 * Address 2 City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Postal Code * Primary Phone Number * Secondary Phone Number Email * *We will use your email address to send you important information and reminders, including vaccines/treatments coming due, and to allow horse owners access to important documents. If you will be needing access to Coggins (EIA) certificates for your horses, it is very important that you provide us with the same email address you will use to register for Global Vet Link. I prefer to receive vaccine reminder postcards in the mail Photographs and video of patients and staff are taken on a regular basis for use by PAH in advertising, web/social media content, and community/client education. Pembroke Animal Hospital may use my pet’s first name, breed, image, and/or story for purposes including advertising, web/social media content, and community/client educationI prefer that photos/video not be taken of my pet Prior Veterinarian How did you hear about our clinic? Pembroke Animal Hospital requires payment in full at the end of your pet’s visit and/or at time of discharge. For surgery or hospitalization a deposit may be required, and the balance is due upon your pet’s discharge from the hospital. We are happy to accept cash, check, money order, Visa/Mastercard, American Express, Discover and Care Credit. All clients are responsible for full payment at the time of service unless specific arrangements are made prior to the start of your pet’s treatment. You are responsible for payment for all products and services rendered, even if a final bill is not completed at time of your visit. Accounts unpaid after 45 days from day of service are subject to a delinquent fee of $35.00. Furthermore, any unpaid balance is subject to a 2% monthly (24% annual) finance charge. If we have to submit your unpaid account to a collections process you will be responsible for all charges our practice incurs including late fees, finance fees, collection cost, staff costs, court filing fees and reasonable attorney’s fees. Any returned checks or credit card payments will carry a $30.00 service charge. I verify that the information I have provided is accurate. I authorize the veterinarians and staff of Pembroke Animal Hospital to examine, prescribe for, and treat my pets, and assume responsibility for all charges incurred in the care of my animals. I authorize the release of my pets’ records to Pembroke Animal Hospital from the veterinarian(s) listed above. I have read and understand the financial policy of Pembroke Animal Hospital and agree to its terms. Please Initial to Sign * Today's Date *
