Name: Maplebrook Pet Care Center
Address: 2811 White Bear Ave, Maplewood, MN, 55109, US
Telephone: 651-788-9006
Price range: $$

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 Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Day-Time Phone*
Mobile Phone
Email*
Enter Email Confirm Email
Co-Owner Information
(Optional)
Name
First Last
Phone
Relationship to Primary Owner
Referral Information
How did you find out about our practice?*
- Internet Search / Website
- Clinic Location / Drive-by
- Clinic Sign
- Newspaper / Print Media
- Social Media (Facebook, Instagram, etc.)
- Open House/Event
- Personal Referral
- Other - please specify below
If Other, please specify:
If Personal Referral, who can we thank for this referral?
Please provide their First and Last name
Pet Information
Pet's Name*
Species*
- Dog
- Cat
- Rabbit
- Ferret
- Rodent
- Bird
- Reptile
- Other - please specify below
If Other, please specify:
Breed*
If unknown, please provide your best guess, or enter "Mix"
Color(s)*
Date of Birth or Age*
If unknown, please provide your best guess
Special Identification
Tattoo, microchip, etc.
Sex*
- Neutered Male
- Intact Male
- Spayed Female
- Intact Female
- Unknown
Does your pet have any previous medical history?
If so, please list their previous clinic(s) here
Please use the following box to give us any other relevant information about your pet (such as allergies, medical conditions, etc)
Consent and Release Options
Consent for Release of Vaccine Information
Would you like to authorize Maplebrook Pet Care Center to release your pet's vaccination status to third parties when requested at any time in the future? Third parties include, but are not limited to: boarding facilities, groomers, or other veterinary clinics/hospitals.
- Yes, I authorize Maplebrook to release vaccine information as stated.
- No, I DO NOT authorize Maplebrook to release vaccine information as stated without my consent.
Consent for Media Release
Would you like to authorize Maplebrook Pet Care Center to release portions of your pet's history, including your pet's FIRST name, personal recollections, radiographs, photographs, video images or other images to use with media entities including, but not limited to: Facebook, X (Twitter), Youtube, Instagram, TikTok, Pinterest, or our personal website?
- Yes, I authorize Maplebrook to release my pet's information as stated.
- No, I DO NOT authorize Maplebrook to release my pet's information as stated.