Thank you for considering Brooklyn Road Veterinary Clinic for your pet's needs. Please fill out our new client/patient registration form in entirety to ensure we can provide you and your pet with the best possible care.

Have you ever brought a pet to Brooklyn Road Veterinary Clinic before? *

Yes
No

Owner's Name *

First

Last

Email *

Main Contact Number *

Secondary Contact Number

Address *

Address Line 1

Address Line 2

City

State

Zip Code

How Would You Prefer To Be Contacted?

Is There a Spouse/Partner/Family Member Who Should Be Listed On Your Account?

Yes
No

Name of Spouse/Partner/Family Member

First

Last

Please tell us how we can refer to the above person appropriately. (spouse, etc)

Spouse/Partner/ Family Member Contact Number:

In Case of Emergency

Is there anyone else (besides above listed contacts) who should be listed on your account, who has ongoing permission to make medical decisions for your pet(s)?

Yes
No

How did you hear about us?

Please tell us who we may thank for your referral!

Pet's Name *

Upload a Picture of Your Pet

Click or drag a file to this area to upload.

Species *

Dog
Cat

DOB/Age of Your Pet *

Breed & Color (If your cat is not a known breed, do they have long, medium or short hair?) *

Sex *

Male
Neutered Male
Female
Spayed Female

Is Your Pet Microchipped? *

Yes
No
I Am Not Sure

Microchip Number (if known)

Primary Reason for Visit to Brooklyn Road Veterinary Clinic? *

Do You Already Have a Scheduled Appointment? *

Yes
No

Appointment Date / Time *

Date

Time

Previous Veterinarian(s) *

If none, please let us know that!

Upload Previous Veterinary Records

Click or drag a file to this area to upload.

Do You Have More Than One Pet At Home?

Yes
No

Pet's #2 Name *

Upload a Picture of Your Pet

Click or drag a file to this area to upload.

Species *

Dog
Cat

DOB/Age of Your Pet *

Breed & Color (If your cat is not a known breed, do they have long, medium or short hair?) *

Sex *

Male
Neutered Male
Female
Spayed Female

Is Your Pet Microchipped? *

Yes
No
I Am Not Sure

Microchip Number (if known)

Do You Have More Than 2 Pets At Home?

Yes
No

Pet's #3 Name *

Upload a Picture of Your Pet

Click or drag a file to this area to upload.

Species *

Dog
Cat

DOB/Age of Your Pet *

Breed & Color (If your cat is not a known breed, do they have long, medium or short hair?) *

Sex *

Male
Neutered Male
Female
Spayed Female

Is Your Pet Microchipped? *

Yes
No
I Am Not Sure

Microchip Number (if known)

Pet's #4 Name *

Upload a Picture of Your Pet

Click or drag a file to this area to upload.

Species *

Dog
Cat

DOB/Age of Your Pet *

Breed & Color (If your cat is not a known breed, do they have long, medium or short hair?) *

Sex *

Male
Neutered Male
Female
Spayed Female

Is Your Pet Microchipped? *

Yes
No
I Am Not Sure

Microchip Number (if known)

This form supports telling us about 4 pets in your home. If you have more than 4 pets, please let our office know and we will happily collect information to add them to your account.

Client Policies and Procedures

We want you to be aware of and understand the following policies and procedures for all clients.

We Love Social Media! Do we have your permission to post pictures of your pet(s), you and your pet(s) and/or your pet(s) and our team on Facebook, Instagram, Twitter, www.brooklynroadvet.com and any other marketing and/or other social media outlets we may choose to use? *

Yes
No

Brooklyn Road Veterinary Clinic uses email, text and our own hospital app for communications regarding our patient's reminders for health care needs. Do we have your permission to contact you via email, text and/or our app regarding these reminders *

Yes
No

FINANCIAL POLICY:

Our office accepts Visa, Mastercard, Discover, and American Express. We also accept cash and checks (only with verification of valid drivers license or other ID at time of payment).

In addition, we also offer several 3rd party financing options for our clients via Care Credit. We accept a variety of Care Credit plans based on the total transaction amount for your pet. Care Credit requires that payment only be made for services as they are rendered, we cannot charge services to your account in advance. Use of Care Credit requires that the card be present every time and that two forms of identification are verified. We appreciate your understanding of our desire to protect your account/identity.

As financing options are offered, we cannot offer additional in-house payment plans for our services. Clients needing additional financial support are encouraged to apply for Care Credit with a co-signer.

Full payment is due at the time of service. This includes any charges/fees agreed to by my authorized proxy. Our team is happy to provide any client with a written treatment plan prior to services being rendered. Client will be responsible for a 1.5% monthly finance charge on accounts over 30 days and any collection and/or legal fees on accounts over 90 days. Your signature below indicates your agreement with these policies.

TREATMENT CONSENT:

By signing this document, I declare I am the lawful owner of all listed pets and all information is true and correct to the best of my knowledge. I hereby authorize the veterinarian(s) of Brooklyn Road Veterinary Clinic to examine, prescribe for or treat my pet(s) to the best of their abilities. I assume responsibility for all charges incurred in the care of this animal. I acknowledge that medical information will not be released to anyone not indicated on this form without my express verbal and/or written permission with the exception of another veterinary facility.

Signature

New Client Enrollment Form

New Client Enrollment

In Case of Emergency

Client Policies and Procedures

We proudly serve the pets of Jackson, MI and beyond.

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