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Home » New Client Registration Form

New Client Registration Form

Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.

Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.

Welcome to Ebenezer Animal Hospital! Do you need to make an appointment?
- Yes- Please have someone contact me
- No- I already have an appointment scheduled
- No- Not at this time. I would just like to get established at EAH
Pet Owner's Name
Name*

First

Last
Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country
Mobile Phone*
Spouse/Partner Cell phone (if applicable)
Alternate phone number
Alternate number description
If an alternate number is listed above, please indicate where we will reach you at this number (Work, home, etc)
Email*

Enter Email

Confirm Email
Occupation and Employer
Co-owner's Name & Contact #

First

Last

Phone number
How did you hear about our practice?
- Google
- Other internet Search
- Clinic Location / Sign / Drive by
- Friend / Family Referral
- Newspaper / Print Media / Yellow Pages
- Other
If Other, please specify:
If Personal Referral, is there someone we can thank for this referral?
Please use this area to give us any other relevant information about yourself or your family
Pet Information

Pet #1
Pet's Name*
Species*
or if other species
Breed (if known)
Color
Date of Birth or Age (if known)
Special Identification (tattoo, microchip, etc.)
Sex
Previous Veterinary Practice (if any)
Date of last vaccines (if known)

MM slash DD slash YYYY
Is your pet on any medication or supplement?
- Yes
- No
If Yes, please list the medication or supplement
Does your pet have allergies or drug reactions?
- Yes
- No
If Yes, please list the allergies and reactions
Are there any current or past medical conditions of which we should be aware?
- Yes
- No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Please use the following box to give us any other relevant information about your pet
Pet Information

Pet #2
Pet's Name
Species
or if other species
Breed (if known)
Color
Date of Birth or Age (if known)
Special Identification (tattoo, microchip, etc.)
Sex
Previous Veterinary Practice (if any)
Date of last vaccines (if known)

MM slash DD slash YYYY
Is your pet on any medication or supplement?
- Yes
- No
If Yes, please list the medication or supplement
Does your pet have allergies or drug reactions?
- Yes
- No
If Yes, please list the allergies and reactions
Are there any current or past medical conditions of which we should be aware?
- Yes
- No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Please use the following box to give us any other relevant information about your pet
Pet Information

Pet #3
Pet's Name
Species
or if other species
Breed (if known)
Color
Date of Birth or Age (if known)
Special Identification (tattoo, microchip, etc.)
Sex
Previous Veterinary Practice (if any)
Date of last vaccines (if known)

MM slash DD slash YYYY
Is your pet on any medication or supplement?
- Yes
- No
If Yes, please list the medication or supplement
Does your pet have allergies or drug reactions?
- Yes
- No
If Yes, please list the allergies and reactions
Are there any current or past medical conditions of which we should be aware?
- Yes
- No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Please use the following box to give us any other relevant information about your pet
Social Media Release*
I grant to Ebenezer Animal Hospital,
its representatives and employees, the right to take
photographs of me and/or my pet, and to use and publish the same in print and/or electronically.
I agree that Ebenezer Animal Hospital
may use such photographs of my pet and/or me with
or without my name and for any lawful purpose,
including, for example, such purposes as publicity,
illustration, social media, advertising, and Web content.
- EAH MAY take and post photos of me and/or my pet
- EAH may NOT take and post photos of me and/or my pet
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Call us or schedule an appointment online!
2
Meet with a doctor for an initial exam.
3
Put a plan together for your pet.

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(803) 366-1950

2445 Ebenezer Rd.,
Rock Hill, SC 29732

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Home
Our Hospital
Services
Client Resources
Contact Us
- Employment Opportunities
Telemedicine
Make An Appointment

Monday

7:30am – 6:00pm

Tuesday

7:30am – 6:00pm

Wednesday

7:30am – 6:00pm

Thursday

7:30am – 6:00pm

Friday

7:30am – 6:00pm

Saturday

7:30am – 12:00pm

Sunday

Closed

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