Sahara Pines Animal Hospital

6533 West Sahara Avenue
Las Vegas, NV 89146-2909

(702)876-7580

saharapinesah.com

New Client Registration

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for giving us the opportunity to care for your pet.  We'll be happy to answer any question you have about your pet's health.  To ensure the best care possible, please take the time to fill in this form completely.

New Client

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Primary Phone (required)
Phone TypePhone Number (required)
Secondary Phone
Phone TypePhone Number
E-Mail Address :
Spouse/Other Name
First Name
Last Name
Spouse/Other Phone
Phone TypePhone Number
Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed:

Sex: (required)
Male
Female


Neutered/Spayed
Neutered
Spayed


Are your pet's vaccines current?
Yes
No


Do you have pet's medical records?
Yes
No


Medical records at another veterinary Practice?
Yes
No


Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No


Would you like us to call you for your appointment
Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

How did you hear about our hospital?
Pet Store
Yellow Pages
Drive-by
Live close
Walk-in
Previous client
If referred by a client, who may we thank?

Please Read
I understand, by indicating I agree and submitting this registration, that I assume responsibility for all charges incurred in the care of my pet by the doctors at Sahara Pines Animal Hospital and that charges are due and payable at the time of service. Sahara Pines Animal Hospital does not provide any billing options (please ask about Care Credit payment plans). Payment may be accepted in the form of cash, personal local check (with a valid Nevada driver license), Visa, Mastercard, Discover, American Express and Care Credit. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Sahara Pines Animal Hospital's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges. I also certify that I am the owner or duly authorized agent for the owner of the above described pet(s) and authorize Sahara Pines Animal Hospital to examine, prescribe for or treat said pet(s).
I have read this statement and - (required)
I Agree
I Disagree



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