Download our app before your visit! Once you submit this form and your chart is made in our system you will be able to create an account using the email address you provide below. 
Primary Contact Name
Secondary Contact Name
How did you hear about us?
Pet #1
Species (1)
Sex (1)
(If applicable. If you have more than two pets please fill out an additional form)
Species (2)
Sex (2)
We love social media! We would like your consent to share your pet's image on our social media pages and website. Your full name and personal information will never be used.
If you have any digital medical records please attach them here. If you have paper records you could always take well-lit photos of them with your phone and upload those as well!
One file only.
100 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Our veterinary team is committed to our values of Empathy, Compassion, Understanding and Open Communication. We ask that you partner with us and share in these values. We will not tolerate yelling, swearing or any type of abuse to our team. If something is not right, we want to help address it, in a respectful manner.

Sincerely, The Doctors and Team at Crescenta Cañada Pet Hospital

I confirm that the above information is correct and that I am the owner or authorized agent of the patient listed above. I hereby authorize the veterinarian to examine, prescribe for and treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I understand that payment is always due in full at the time of service. I recognize that financial concerns should be discussed prior to exam and treatment. For your convenience we accept Visa, MasterCard American Express, cash and checks with proper identification. Please discuss any financial questions with the front desk.
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