Client and Patient Registration Form

CLIENT REGISTRATION FORM

Centre Street Veterinary Clinic
Name*

First NameLast Name
Address*

Address

Street Address Line 2

CityState / Province

Postal code
Primary Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Spouse/Other Name
If applicable
Spouse/Other Phone Number
Please enter a valid phone number.
Alternative contacts
Pet Sitter, Friends, Family, etc.
E mail
example@example.com
Previous Veterinary Clinic
If applicable
How did you hear of us?
Website, friend/family referral, etc.

PATIENT PROFILE
Pet's Name*
Species*
Dog/Cat/Rabbit
Breed*
Birthdate*

MonthDayYear
DOB or estimated age
Color*
Gender
Male/Female
Spayed/Neutered?
Type yes/no or leave blank if unsure
Tattoo #
Microchip #
Date of previous vaccinations (if applicable)

MonthDayYear
Date
Do you have insurance?
Type "yes" or leave blank if not applicable
Name of Company and Policy Number (if known)
File Upload

Provide previous veterinary records (if applicable)
Cancelof
Do you want to submit information for an additional pet?

YesNo

PATIENT PROFILE
Pet's Name
Species
Breed
Birthdate

MonthDayYear
DOB or estimated age
Color(s)
Gender
Male/Female
Spayed/Neutered?
Type yes/no or leave blank if unsure
Tattoo #
Microchip #
Date of previous vaccinations (if applicable)

MonthDayYear
Date
Do you have insurance?
Type "yes" or leave blank if not applicable
Name of Company and Policy Number (if known)
File Upload

Provide previous veterinary records (if applicable)
Cancelof

I assume responsibility for all charges incurred in the care of the animal(s) listed. I also understand that these charges will be paid at the time of release and that a deposit may be required for veterinary care of my pet. Please be informed that do not accept cheques.

As owner/caretaker of the animal(s) listed, I authorize the doctors and staff at Centre Street Veterinary Clinic to treat this animal as recommended and explained by the doctor with my permission. I also agree to be responsible for payment of such treatments upon completion of services.
Date*

MonthDayYear
Date
Signature*

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