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.
  • Owner's Name

  • Pet Information

  • Pet's Current Health

  • Food brand & Amount fed per day (ex: 2 cups per day)
  • Pet Photo Upload (2MB max) - Please upload a photo of your pet for your records or you can email an photo to us at CoastalVeterinaryDE@gmail.com
    Accepted file types: jpg, gif, png, jpeg.
  • Financial Policy & Authorization

  • Financial Policy

    Coastal Veterinary policy requires payment at time of service. Accepted forms of payment are Cash, Check, Credit (Visa, MasterCard, Discover, or American Express). We can also help you apply for Care Credit financing should the need arise. Information is readily available at the front desk. There is no hospital administered financing program. If you have pet insurance, payment is due at the time of service. Please contact your insurance company for further information.

    A written estimate will be provided at the time of admission. Depending on the nature of medical care, actual cost may vary. We will attempt to contact you as soon as possible if the cost exceeds the high end of the estimate by 20%.

    On admission, a deposit of 50% of the high end of the estimate is required. The balance is to be paid at the time of discharge. We cannot make exceptions to this policy.

    I understand that if there is a balance due, for any reason, and it is not paid per Coastal Veterinary requirements, I will be responsible for any collection and/or attorney fees that are incurred in the attempt to collect the debt.

  • Authorization

    By clicking submit, you agree to the financial policy and hereby authorize the veterinarian to examine, prescribed for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment.