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Registration

//Registration
Registration2018-08-21T16:57:05+00:00

New Patient Registration

PLEASE DO NOT FILL OUT AND SUBMIT UNLESS YOU HAVE SCHEDULED AN APPOINTMENT.

New patients receive $15 OFF your pet’s first exam.

Form must be filled and submitted at least 12 hrs before scheduled appointment. In order to honor this discount, you must be on time for your appointment. Offer only valid for new patient’s first visit. Please provide the information below as completely as possible. All information is strictly confidential.

Owner Information

Patient Information

Gender: MaleFemale
Spay/Neuter: Not ApplicableNeuteredSpayed

Does your pet have any history of aggression towards people or other animals?
YesNo

Referral/Previous Veterinarian Information

Do you authorize Coral Breeze to get previous records
YesNo

Check to confirm you are the owner and/or agent of the above animal and have the authority to consent treatment if any when it is needed.
Check to acknowledge you understand that we accept VISA, MASTERCARD, DISCOVER, AMERICAN EXPRESS, and we offer Care Credit if you need a payment plan. NO CHECKS ACCEPTED.
Check to acknowledge you understand that these charges will be paid at the time of release, and that a deposit may be required for hospitalization, surgery, boarding or treatment.
Check to confirm you agree that in the event of default, you (Owner) will be responsible for any legal fees and/or collections costs and a finance charge of 1.5% per month (18% per annum)

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