Client & Patient Registration

Please complete all required fields to register with our clinic

Do you have an appointment?

Yes, I have an appointment

No, I'm a walk-in

✓

Welcome!

Since you have an appointment, please check in with the receptionist at the front desk.

They will help you get checked in right away.

Select Your Location

Mesa

North Valley

Chandler

Please select a location

Owner Information

First Name * First name is required

Last Name * Last name is required

Email Address * Valid email is required

Cell Phone * Cell phone is required

Home Phone

Alternate Phone

Employer

Street Address

Apt, Suite, Unit (optional)

City

State/Province

ZIP/Postal Code

Secondary Owner (Optional)

Add a spouse, partner, or co-owner who may bring in the pet

First Name

Last Name

Pet Information

Pet's Name *

🐾 Select Existing Pet

Click ▼ to select an existing pet, or type a new name Pet name is required

Species * Species is required

Breed

Gender * Gender is required

Color/Markings

Date of Birth (or approximate)

Known Allergies

Reason for Visit * Reason for visit is required

Veterinarian Information

Regular Veterinary Clinic

How Did You Hear About Us?

Previous Visit Hospital Sign Magnet Online Search/Website Friend/Family Regular Veterinarian

Referred by (name of friend or family member)

Permission to Treat

Payment Policy: Payment in full is due at the time your pet is discharged from 1st Pet Veterinary Centers. You will be provided with a written estimate of charges. A 75% deposit will be required if your pet is hospitalized.

Authorization: I authorize the doctors to perform treatment for my pet. I assume responsibility for all charges incurred in the care of this animal.

I agree to the above terms and authorize treatment *

You must agree to the terms to submit