New Client Registration Form

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.

Are you a current client?

Yes No

Primary Contact Name

Alternate Contact Name (if applicable)

Mailing Address

City

State / Province / Region

ZIP / Postal Code

Main Phone Number

Main Phone Type

Name Associated with Main Phone

Alternate Phone

Alt Phone Type

Name Associated with Alt Phone

Pet's Name

Gender

Spayed/Neutered?

Birthdate (MM/DD/YY)

Weight (if known)

Species

Breed

Color/Markings

Microchip ID# (if known)

What is the reason you're submitting records? (New Client and/or Pet for Wait List, Wellness and Vaccines, Illness, 2nd Opinion, Surgery, etc)

Please include any specific info you have about your pet (previous vet visits, vaccines, health concerns, etc). You may also attach records using the Upload Link Below.

How did you hear about us? (select one)

Please submit all your information using the button below. We will get back to you regarding your records submission as soon as possible. If you have other records you could not fill or attach to this form, you can email them directly to info@manchestervets.com. Thank you!

PAYMENT & BILLING AGREEMENT

Payment is due when services are rendered unless prior arrangements have been approved in writing. A valid photo ID is required before an account is created. Accepted payment methods: Cash, Check, Money Order, Visa, MasterCard, and Discover. Returned checks are subject to a $25 fee.

Any balance unpaid after 30 days is subject to a finance charge of 8% annually. If an account is referred to collections, the responsible party agrees to pay applicable collection agency fees, up to 30% of the outstanding debt, and related costs, including reasonable attorney's fees.

APPOINTMENT CANCELLATION & NO-SHOW POLICY

We understand that plans can change. Please provide at least 24 hours' notice to cancel or reschedule an appointment. Appointments may be cancelled by calling our office, leaving a voicemail, or cancelling online.

A $50 fee will be charged for any appointment missed or cancelled with less than 24 hours' notice. The $50 fee must be paid before another appointment can be scheduled. Providing adequate notice allows us to offer appointment times to other pets in need of care.

AI-ASSISTED SCRIBE CONSENT

Manchester Veterinary Services uses AI-assisted scribe recording technology during appointments to assist with accurate medical records and communication. By signing below, I acknowledge and consent to this use.

PET PHOTO & RECORDING CONSENT

I authorize Manchester Veterinary Services to take photographs and/or recordings of my pet during visits. These may be used for educational, promotional, or marketing purposes, including print materials, advertisements, videos, websites, online platforms, and social media.

CLIENT ACKNOWLEDGMENT & FINANCIAL RESPONSIBILITY

By signing below, I certify that I am at least 18 years of age, accept financial responsibility for all charges incurred on this account, and acknowledge that I have read, understand, and agree to all terms of this agreement.

Signature of Responsible Party

Printed Name

Date