EAGLE RIVER ANIMAL HOSPITAL - NEW PATIENT REGISTRATION

Name

First NameLast Name
Email
example@example.com
- Pet's Name
- DogCatOtherOther
- Breed
- Color
- Microchip #
- MaleMale - NeuteredFemaleFemale - Spayed
- Date of Birth
  
  MonthDayYear
  Date
- Age
- NoYes
- What are the approximate dates of your pet's most recent vaccinations or treatments?
- Canine
- Canine - Rabies
- Canine - Distemper
- Canine - Lyme
- Canine - Bordetella
- Canine - Leptospirosis
- Canine - Deworming
- Feline
- Feline - Rabies
- Feline - Distemper
- Feline - Leukemia
- Feline - FIP
- Canine & Feline Test Date or Product
- Heartworm Test
- HW Preventative
- Feline Leukemia Test
- Flea/Tick Control
- Previous animal hospital where we may request recent records?
- NoneYes, described below
- Describe any previous illnesses, behavior problems, or surgeries your pet has had:
- NoneYes, described below
- Please list current medications (and dosages) and supplements:
- YesNo
- I authorize the veterinarian(s) to examine, prescribe for, and treat the above described pet.
- Signature
- Date
  
  MonthDayYear
  Date
- StrayShelterPrivate homeBreederRescue organization
- When?
- State?
- Indoors onlyOutdoors OnlyIndoors mostly and on leash/in fenced yard sometimesHuntsIndoors sometimes and outdoors on own sometimesRegularly travels out of region/state
- If your pet regularly travels out of state, where?
- If your pet regularly travels out of state, when?
- NeverOnce a year or less2-3 times a year4 or more times a year
- NeverOnce a week or less2-5 times a weekDaily
- DryCanned
- Brand Name
- How much?
- Treats/Chews
- How many?
- Table Food
- Upload past patient records here: (if available)
  
  Browse Files
  
  Cancelof
- Should be Empty: