Online Registration Form

If this is your pet's first time visiting us, please fill out our Online Registration Form using one of the options below.

OPTION 1
Complete Online

Complete and submit the form below.

OPTION 2
Complete on Arrival

If you prefer, you can complete the form when you get to our hospital.

Online Registration Form

Please provide us with the following information.

Client Information

Owner Last Name *

Owner First Name *

Address *

City, State, Zip Code *

Home Phone *

Cell Phone *

Email Address *

Patient Name *

Species *

Sex *

Breed *

Age *

Color *

Veterinarian's Name *

Which clinic usually sees your pet? *

Consent for Examination / Treatment

Please check each box to show you have read and understand the following:

I authorize Northeast Veterinary Referral Hospital and its medical staff to initiate emergency care and treatment for the pet presented if needed. This may include (but is not limited to) oxygen therapy, placing an IV catheter (fur will be shaved), administering pain medicine and other urgently needed medications. *

Read & Understood

Once your pet's exam is complete, the doctor will consult with you regarding recommended diagnostics and a health treatment plan. An estimate of the total costs associated with the tests and the treatment plan will be explained to you. An additional deposit, if needed, will be required at this time. *

Read & Understood

If provided, we may occasionally use your email address to communicate with you. We will not sell or lease this information to any third party at any time, and we will not share this information with any parties outside of NVRH without your consent. *

Read & Understood

I consent to the audio & video-recording of myself and my pet and the use of these recordings (including telephone conversations) for the quality and training purposes of NVRH employees. *

Read & Understood

By submitting this form, I certify that I am the owner or authorized agent for the animal described above. I consent to have the veterinarian and staff of NVRH examine and treat my pet. I certify that all of the information I have provided above is true to the best of my knowledge. I am over 18 years of age. I have been given the opportunity to review and ask questions which I may have about the material above. I consent to have copies of my pet's medical record faxed to my referring veterinarian.

Emergency Life Saving Procedures

It is the nature of emergency medicine that situations which cannot be predicted and which require emergency treatment, may arise. In those situations, treatment often must be initiated immediately and without the veterinarian having time to contact the owner. Because of this, we require all owners to state their wishes with regard to CPR and other emergency life-saving procedures before leaving their animals. Please be aware that the cost for basic CPR can range from $300 - $500.

Please read carefully and select only one of the options below:

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From Happy Pet Owners

Dr. Hassinger and his staff are beyond reproach in their services. Their compassion, professionalism and expertise have benefited our pets many times over the years.
David K.

Online Registration Form

OPTION 1Complete Online

OPTION 2Complete on Arrival

Online Registration Form

Client Information

Consent for Examination / Treatment

Emergency Life Saving Procedures

From Happy Pet Owners

OPTION 1
Complete Online

OPTION 2
Complete on Arrival