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134 Medical Drive, Advance, NC 27006

P: 336-645-5993

F: 336-998-1670

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NEW CLIENT REGISTRATION FORM2016 PDF

To expedite the check-in please feel free to fill out this new client form prior to your appoinment.

Owner Information
Name of Owner
Name of Spouse/Partner
Address
City
State
Zip
Owner Contact
Home Phone*
Cell Phone*
Work/Other Phone
Spouse/Partner Contact
Home Phone
Cell Phone
Work/Other Phone
Owners Email
Spouse/Partner Email
To be used for e-mail reminders, special events, offers and client communication.
How did you hear about us?
Pet Information
Pet Name
Date of Birth
Type of Pet
Breed
Color
Sex
Authorization Agreement
As owner of record, I hereby authorize the doctor(s) to examine, prescribe for, and treat any animal(s) I present to Hillsdale Animal Hospital. I assume responsibility for all charges incurred in the care of this/these animal(s). I also understand these charges are to be paid at the time of release and that a deposit may be required for surgical treatment or hospitalization.
Type Name as Signature
Date

Accepted methods of payment: Cash, Check*, Mastercard/ Visa, Discover, AmEx and Debit Cards.
**Returned checks will carry a fee. Unpaid checks will be turned over to Sheriffs Department.

Make An Appointment

Hillsdale Animal Hospital of Advance is dedicated to helping you achieve your wellness objectives.


Hillsdale Animal Hospital


134 Medical Drive


Advance, NC 27006


Phone: 336-645-5993


Fax: 336-998-1670


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Virginia-Maryland Regional College of Veterinary MedicineCollege of Veterinary Medicine University of Illinois