Crossroads Animal Hospital

123 Nashua Road
Londonderry, NH 03053

(603)437-1010

crossroadsanimal-hospital.com

If you are a new client to us, please call (603) 437-1010 to schedule an appointment prior to filling in this form.

Existing clients please use this form to update your information.

Thank you!

Client Information Form

Are you new to us or a current client? (required)
New Client
Current Client


Name (required)
First Name (required)
Last Name (required)
Spouse/Co-Owner Name
First Name
Last Name
Name(s) and relationship(s) of anyone who has permission to make medical decisions for your pet(s).

Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Phone (required)
Phone TypePhone Number (required)
Secondary Phone (if applicable)
Phone TypePhone Number
E-Mail Address :
Occupation

Spouse/Co-Owner Phone Number
Phone TypePhone Number
Spouse Occupation

How do you prefer to receive appointment confirmations?
E-Mail
Phone Call
Text Message


Which phone number can receive text messages?
Primary
Secondary


How do you prefer to receive annual reminders for exams and vaccines? (required)
E-mail
Postcard


If you are new to us, why did you select us?
Referral
Location
Facebook
Other Internet Source


Is there someone we may thank for referring you?

Patient Information
Pet's Name (required)

Age: Birth date or Years/Months

Type of Pet (required)
Canine
Feline


Breed:

Sex:
Male
Female


Neutered/Spayed
Neutered
Spayed


Color

Does your pet have a microchip?
Yes
No


Do you have pet insurance?
Yes
No


If Yes, please indicate the insurance company.

Do you have your pets medical records?
Yes
No


Are the medical records at another veterinary practice?
Yes
No


Please list any additional pets here

Please Read
I authorize Crossroads Animal Hospital, PC, to publish/display any photos/videos taken of my pet(s) in Crossroads Animal Hospital's facility or its publications (EX:website, Facebook).
I have read this statement and - (required)
I Agree
I Disagree


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 Crossroads Animal Hospital and that charges are due and payable at the time of service. I understand that I can request a written estimate for goods and services provided to me by Crossroads Animal Hospital. I also understand that the acceptable forms of payment are cash, personal checks (processed electronically through TeleCheck and any checked returned unpaid will have a fee incurred), MasterCard, Visa, Discover and Care Credit.
I have read this statement and - (required)
I Agree
I Disagree



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