Client Registration | www.vecmnh.com

First name

Last name

Secondary Contact

Address

Cell Phone

By selecting "accept" below, you consent to receive SMS text messages from the Veterinary Emergency Center of Manchester. You may update your preference and cancel your consent by notifying us at any time or by replying CANCEL/STOP to any messages you recieve from us. Standard message and data rates apply.

Email

Owner's Date of Birth (for pharmacy regulations)

Pet Name

Species

Dog

Cat

Other

Color

Gender

Spayed Female

Intact Female

Neutered Male

Intact Male

Pet's Date of Birthday (If unknown, please estimate age)

Is your pet on any medications? If so please list below. If no, please write none.

Primary Veterinary Hospital

Reason for visit

Rabies Vaccine Status

Up to date

Not up to date

Unknown

Have you been a client here previously?

Yes

No

The initial emergency exam fee is $195. Following the exam you will be given an estimate for any recommended diagnostic testing and/or treatment. I understand that payment is due at the time of service. By checking this box, you are stating that you have read and agree to the financial policy.

Please note that we do not accept checks or offer payment plans. How would you like to pay today?

Visa/Mastercard/Discover/American Express

Care Credit

Scratch Pay

Cash

I understand that if my pet presents for a non-critical injury or illness, there will be a wait as we treat the most critical or life threatening cases first.

I have read and agree with this policy.

The Veterinary Emergency Center of Manchester has a ZERO TOLERANCE policy regarding inappropriate behavior of any kind. By checking this box below, you acknowledge that any profane, abusive or hostile behavior or language directed at any member of our team will result in immediate removal from the hospital and termination of access to this facility in the future.

I authorize the Veterinary Emergency Center of Manchester to publish/display any photos/videos taken of my pet(s) in this facility or its publication (eg: website/social media)

YES

NO

Signature

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