Thank you for giving us the opportunity to care for your pet. We'll be happy to answer any questions you have about your pet's health. To insure the best care possible, please take the time to fill in this form completely. Thank you!
REGISTRATION
Date:
    
Owner:
 Address:
 Email Address:
Spouse:
 SS#:
 Home Phone:
Work Phone:
 Spouse Work Phone:
 Emergency Contact Name:
How did you learn of our clinic?:
 If recommended, by whom?:
Number of pets.
Dogs:

Cats:

Other (specify):
Reason for visit:
PET HEALTH HISTORY
Name of pet:
 Dog Cat Other
Breed:
Color:
Birthdate:
Male        Neutered
Female       Spayed
Vaccination History (Date and type of last vaccinations):
Please check any symptoms or problems that you have noticed about your pet.
Behavior Problems
Lack of Appetite
Sneezing
Bleeding Gums
Limping
Thirst and/or Urination Increased
Breathing Problems
Loss of Balance
Vomiting
Coughing
Scooting
Weakness
Diarrhea
Scratching
Other:
Eye Bulging or Bloodshot
Seems Depressed
Gagging
Shaking Head
Pet's current medications:
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 this animal. I also understand that these charges will be paid at the time of release and that a deposit may be requires for surgical treatment.

Signature of Owner (Type your name):
 Date:
Method of payment: Cash Check MasterCard Visa Other
 
 
 
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