Client and Pet Registration Form

Client and Pet Registration Form
Client Information*

First Name (and Spouse)MiddleLast Name
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone*
Employer*

Employer Name

Street Address

CityState / Province

Postal / Zip Code
Work Phone*
E-mail*
example@example.com
Send me email reminders

YesNo
How did you hear about us?
If you were referred by someone, let us know who so we can thank them!
Referrer's Name and Cell Phone
Pet Information

Tell us about your pet!
Pet Name: Pet Name
Pet Birthdate (if known): Birthdate 1

Specie (select one): Canine   Feline   Avain   Small Mammal   Reptile

Breed: Breed

Color: Color
Sex (select one): Male   Female

Spayed (female): Yes   No
Neutered (male): Yes   No

Microchip number (if known): Number
REDWOOD PET CLINIC STATEMENT:

I hereby authorize the Doctors (and their designated associates or assistants) to examine, prescribe for, treat, or perform anesthesia/surgery upon the above-described pet. I agree to pay the fees for the services rendered at the time the pet is discharged from the clinic or when service is otherwise terminated. Under extenuating circumstances and at the direction of the Hospital Manager, credit may be extended. A monthly service charge of 1.5% (Annual Percentage Rate 18%) will be applied to all accounts with an outstanding balance past 80 days with a minimum monthly service charge of $2.00.
Signature of Owner or Responsible Agent:*

Clear
Date*
Should be Empty:

Pet Information