New Client Registration Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following form. If you try to submit the form and find that it does not work, please be sure that ALL required* areas are complete. Thank you!Owner Name*Co-Owner NameAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home NumberCell Number*Co-Owner Cell NumberEmail AddressAll Fees Are Due At the Time Services Are RenderedHow did you become aware of our clinic? Drove by Web site Client Facebook Google Yelp Yellow Pages OtherPlease explain:Name of Previous ClinicPhonePersonal Recommendation (Who may we thank?)Pet InformationNameBreedDate of BirthColorMicrochip#SexSpayed or NeuteredYOUR DOG’S VACCINATION HISTORY:RABIESLEPTOSPIROSISDAP PARVOBORDETELLAFECAL (STOOL SAMPLE)HEARTWORM TEST/PREVENTION YOUR CAT’S VACCINATION HISTORY:RABIESFELVFVRCPLEUKEMIA/FIV TESTFECAL (STOOL SAMPLE) Our pet(s) is:IndoorOutdoorEqually Indoor/OutdoorAny previous serious illnesses or surgeries?Any allergies to vaccinations or medications?Is your pet on any special diets or medications?List any behavioral problems that we need to be aware ofConsent: You will be asked to sign a health plan confirming authorization of treatment after a tentative diagnosis. The details of treatment, the risks of treatment, and/or the risk of not treating will be explained to you.May we post a picture of your pet on social media or display it in our lobby?YESNOReason for Visit?Authorization By signing this form, you certify that you are the owner of the animals listed above. I hereby authorize services to be provided for my pet as required for maintaining proper health. I also understand that all fees are and payable when services are rendered, and that I am responsible for any charges incurred due to returned checks or through collection efforts. I authorize the above mentioned hospital/clinic to send all records or recorded statements on my behalf.Date* Type out your full name*If you try to submit the form and find that it does not work, please be sure that ALL required* areas are complete. Thank you!CommentsThis field is for validation purposes and should be left unchanged.
