Baeyens Hauk Veterinary Group New Client Registration

Baeyens Hauk Veterinary Group
Sherwood:
8620 Hwy 107
Sherwood, AR 72120

Argenta:
709 Main Street
North Little Rock, AR 72114

501-837-7106
Client Registration Form
Owners Name:
Email Address:
example@example.com
Address:
Apt:
City:
State:
Zip:
Cell Phone:
Other Phone:
Spouse:
Spouse Phone:
Emergency Contact:
Phone:
Who can we thank for referring you to our practice?
Do you have an appointment scheduled?

Yes No
If so, Date?

Month Day Year
Date
Location?
Patient Information
Patient Name
Age or Date of Birth:

Month Day Year
Date
Species

Canine Feline Avian Reptile
Breed
Color:
Sex

Male Female
Neutered or Spayed?

Yes No
Is your pet microchipped?

Yes No Unknown
Date and location of last vaccinations
Is your pet currently taking any medications, vitamins or supplements? If so, please list:
Is your pet taking Heartworm prevention?

Yes No
What type of heartworm prevention are they taking?

Heartgard Proheart Trifexis Revolution Sentinel
What food/treats does your pet eat?
Does your pet have any known allergies?
Please list any prior surgeries or illnesses
I hereby authorize the veterinarian to examine and treat the above named pet. I assume full financial responsibility for all charges incurred. All professional fees are due at the time services are rendered. We accept cash, checks, all major credit cards, and offer both Care Credit and Scratch Pay.
Signature:

Clear
Date:

Month Day Year
Date
There may be a case when someone other than you may need to bring your pet for treatment. Please list individuals authorized to allow treatment, sign treatment plans, and sign anesthesia consent forms on your behalf. For the safety of your pet, we will not allow anyone unauthorized by you to sign for treatment.
Authorized Individuals:
Are we authorized to post your pet’s picture on our social media platform or web site?

Yes No
Please verify that you are human *
Should be Empty:

Baeyens Hauk Veterinary Group

Client Registration Form

Patient Information