Client Registration

Ethos Veterinary Health Hospitals
Select the Ethos Veterinary Health Hospital at which you are seeking Treatment*
Please select the hospital where you are planning to receive treatment from the dropdown list above. The hospital team do not have access to other hospitals' registration forms. Selecting the wrong hospital, or no hospital, will require you to fill the form out a second time. Thank you for your kindness and understanding.

Owner Information
Title*
First Name*
Last Name*
Date of Birth*
Month
Day
Year

State Guidelines require that the caregiver’s date of birth be recorded when distributing controlled medications.
Email Address*

We will use your email to send appointment reminders, medical communications and a client survey.

Address*
City*
State*
Zip Code*
Preferred Contact Number*
Phone Type*
- Mobile
- Home
- Work
I grant permission to the hospital medical team to text reminders and updates to the mobile number provided here*
- Yes
- No
Secondary Phone Number
Phone Type
- Mobile
- Home
- Work

Co-Owner/Alternate Contact
Co-Owner Title
Co-Owner First Name
Co-Owner Last Name
Co-Owner Date of Birth
Month
Day
Year

State Guidelines require that the caregiver’s date of birth be recorded when distributing controlled medications.
Co-Owner Email Address

We will use your email to send appointment reminders, medical communications and a client survey.
Co-Owner Contact Number
Phone Type
- Mobile
- Home
- Work
I grant permission to the hospital medical team to text reminders and updates to the mobile number provided here
- Yes
- No

Patient Information
We take pictures of your pet for identification and as part of the medical record. These photos are not shared outside of the medical record.
Name of Pet*
Date of Birth or Age of Pet*

Please enter the number of years (7 years), or enter the date of birth in the format: mm/dd/yyyy.
Sex of Pet*
Species*
Species, if Other
What type of bird or other Species of animal?
Breed*
Color*
Date of Most Recent Rabies Vaccination
MM slash DD slash YYYY
Dates of Other Recent Vaccinations
Vaccine Name Date (mm/dd/yyyy)
Pet Insurance Carrier*
Please specify if Other
Policy Number

Ethos Veterinary Health Hospitals

Vaccine Name	Date (mm/dd/yyyy)