New Client/Patient Registration


Are you or your pet new to Colchester Veterinary Hospital?  If so, please fill-out our electronic form for new clients and patients.  Please also provide applicable medical records, specifically vaccine history, for your pet.  By providing us with this information in advanced of your appointment we can save you significant time at check-in.  You also help us out by getting this information entered in our database well in advanced, freeing our receptionists to focus on client and patient needs that require good old fashioned one-on-one.  Thanks!

If applicable, your pet's medical records, especially vaccinations, can be submitted to us the following ways:

1.  Faxed to 860.537.3435
2.  Electronically to ......@colchestervet.net
3.  Uploaded to your Pet Portals account
4.  Physically brought to our office

Please remember that vaccine reminders and rabies tags do not constitute proof of vaccination.  A signed rabies certificate is required for proof of rabies vaccination.

If possible, please try to provide registration forms and all pertinent vaccine/medical history to us at least 24 hours before your scheduled appointment.  This will allow us to review the records and enter your data, saving you and your veterinarian valuable time that should be spent seeing you and your pet.  Thanks!

 

Form - New Client/Patient Registration

----- Owner Information -----
Are you a new client? (required)
Yes
No

Owner's Name (required)
First Name (required)
Last Name (required)
Co-owner's Name (If applicable)
First Name
Last Name
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone
Phone TypePhone Number
Alternate Phone
Phone TypePhone Number
Co-Owner's Alternate Phone
Phone TypePhone Number
E-Mail Address
E-Mail :
----- Pet Information -----
Pet's Name: (required)

Pet's Date of Birth: mm/dd/yyyy

Type of Pet: (required) :
Breed:

Color:

Sex: (required)
Male
Female
Unknown

My pet has been spayed/neutered: (required)
Yes
No
Unknown

Microchip ID:

----- Previous Vaccination/Medical Records -----
I will be submitting vaccination/medical records for my pet: (required)
Yes
No

Applicable vaccination/medical records will be provided via:
Fax
E-Mail
Pet Portals
Physically

Name of Former Veterinary Practice:

Former Veterinary Practice Phone Number:

May we request a transfer of records?
Yes
No

Please Read
I understand,
by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Colchester Veterinary Hospital, LLC and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge.
I have read this statement and - (required)
I Agree

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