Welcome!
Your pet's health is important to us. Please take a few moments to fill out this form completely. Thank you!
Registration
Owner(s)
*
Alternate Authorized Owner(s)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Owner Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
How did you learn about our clinic?
Sign Outside
Website
Yellow Pages
News Paper
Facebook
Recommended
Other
If recommended, by whom?
Back
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Pet Health History
Name of Pet
*
Breed
*
Species
Color
Birthdate/Age
*
Sex
*
Undetermined
Male
Neutered
Female
Spayed
Vaccines current?
*
Yes
No
Reason for visit
*
Primary Veterinary Name
First Name
Last Name
Hospital Name
*
N/A if none
Phone Number
Please enter a valid phone number.
Authorization
I hereby authorize the veterinarian to examine, prescribe for, and/or treat the above described pet. I assume full responsibility for all charges incurred for 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 hospitalization or surgical treatment. I understand that it is the policy of MASH not to refund any medication that is prescribed by the veterinarian once it has left the hospital. I grant to Metropolitan Animal Specialty Hospital (MASH), its representatives, and employees the right to take photographs of my pet. I authorize MASH, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that MASH may use such photographs of me or my pet with or without my name for any lawful purpose, including but not limited to such purposes as publicity, illustration, advertising, or web content.
Signature of Owner
*
Date
*
-
Month
-
Day
Year
Date
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