Pet Registration and History
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!
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Today's Date
Registration
Owner
*
First Name
Last Name
Cell Phone
*
-
Area Code
Phone Number
Home Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Spouse
First Name
Last Name
Spouse Phone
-
Area Code
Phone Number
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone
-
Area Code
Phone Number
Do you qualify for the Senior Discount? (Must be 65 yrs. old or over)
Yes
No
How did you learn of our clinic?
*
Recommendation
Internet
Sign
Yellow Pages
Other
If recommended, by whom?
Number of pets:
*
Rows
How many?
If other, please specify
Dogs
Cats
Other
Pet Health History
Name of pet
*
Type of pet:
*
Dog
Cat
Other
Breed
Color
Birthdate / Age
Vaccination History (Date and type of last vaccinations)
*
Please select any symptoms or problems that you have noticed about your pet
Behavior Problems
Bleeding Gums
Breathing Problems
Coughing
Diarrhea
Eye Bulging or Bloodshot
Gagging
Lack of Appetite
Limp
Loss of Balance
Scooting
Scratching
Seems Depressed
Shaking Head
Sneezing
Thirst and / or Urination Increased
Vomiting
Weakness
Other
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 required for surgical treatment. Please sign below as the Owner:
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Today's Date
Submit
Should be Empty: