Client Registration Form

Client Registration Form
Owner's Name

First NameLast Name
Spouse or Alternate Contact

First NameLast Name
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner's Home Phone Number (if applicable)

Area CodePhone Number
Owner's Cell Phone Number

Area CodePhone Number
Email
example@example.com
Spouse/Alternate Phone Number

Area CodePhone Number
Spouse/Alternate Email
example@example.com
Pet's Information
Name
Birthdate or Estimated Age
Species

DogCatOther
Breed (if known)
Sex

MaleFemaleMale, NeuteredFemale, Spayed
Color(s)
Any Known Issues or Prior History?
We love social media! Do we have your permission to share your pet’s image and/or story on social media, our website and other forms of related media? Your name and personal information will never be shared.
Photo Consent:

YES, I authorize CVC to share my pet(s) photo!No, I do not want my pet(s) photo shared
I hereby authorize the veterinarian to examine, prescribe for or treat the above-described pet(s). I assume responsibility for all charges incurred in the care of this animal. I understand payment is always due IN FULL at the time of service. I recognize that financial concerns should be discussed prior to exam and treatment. I authorize my pet(s) records to be sent to groomers, boarding facilities, pet insurance or other veterinary clinics if requested
Signature
Date

MonthDayYear
Date
Does your pet have previous vet records at another clinic? If you know the name of the other clinic, let us know and we can request records.
Should be Empty:

Client Registration Form

Pet's Information