WELCOME

Thank you for giving us the opportunity to care for your pet. We’ll be happy to answer any questions about your pet’s health.

To insure the best care possible, please take the time to fill in this form completely. Thank You.

REGISTRATION INFORMATION

Date________________

Owner______________________________________________________________ S.S. #_____________________

Address_______________________________________________________________________________________

______________________________________________________________________________________________

Spouse_____________________________________________________________ S.S. #_____________________

Home Phone_____________________ Work Phone _______________________Cell Phone___________________

Spouse’s Phone Number_________________________ Email Address__________________________________

Emergency Contact Name_________________________________________________Phone__________________

How did you learn of our clinic? (Circle one) Yellow Pages Recommendation Sign Other___________________

If recommended, by whom? _______________________________________________________________________

Number of pets: Dogs_____________________ Cats _________________ Other (specify) ____________________

Reason for visit _________________________________________________________________________________

PET HEALTH HISTORY

Name of pet_________________________ (circle one) Dog Cat Other_________________

Breed _________________________ Color_____________________________ Birth date______________________

(Circle all that apply) Male Neutered Female Spayed

Vaccination History (date and type of last vaccinations) _________________________________________________

_____________________________________________________________________________________________

Pet’s current medication__________________________________________________________________________

Describe your pet’s diet __________________________________________________________________________

AUTHORIZATION

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all

charges incurred in the care of the animal. I also understand that these charges will be paid at the time of release and that a

deposit may be required for surgical and emergency treatment.

Signature of Owner___________________________________________________________ Date_________________________

Method of payment (circle one) Cash Check Credit Card Other _________________________