New Patient Registration Form
What day and time is your appointment?
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Client Information
*(Must be 21 years of age or older to register the patient)
Owner Name
*
Co- Owner Name
*
Relation
Cell Phone
*
Please enter a valid phone number.
Home Phone
*
Please enter a valid phone number.
Email
*
example@example.com
Owner Date of Birth
*
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Month
-
Day
Year
Date
Co-Owner Date of Birth
*
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
County
For check writing privileges, please provide your driver’s license #
*
Pet Information
Pet Name
Sex
Spayed or Neutered?
Please Select
Female Spayed
Male Neutered
Date of Birth or Age
Breed
Color
Declawed?
Please Select
Declawed (Front)
Declawed (all four paws)
Not Declawed
Vaccination History
Please indicate date or month and year of vaccine
Distemper (RCP, FVRCP)
*
Rabies
*
Leukemia
*
Other
Feline Leukemia test (Felv) - Date
*
Feline Leukemia test (Felv) - Result
*
FIV test? - Date
*
FIV test? - Result
*
How old was your cat when you acquired it?
*
Where did you acquire your cat?
*
Please Select
Breeder
Shelter
Store
Stray
Private Home
Does your cat go outside?
*
Please Select
Indoor
Outdoor Supervised only
Outdoor Unsupervised
How many other pets are in your household?
Cats
Dogs
Other
What brand of food do you feed?
Dry
Canned
Prior illnesses or surgeries?
Any known allergies or vaccine reactions?
Is your cat
Just a pet
A member of the family
How did you become aware of us?
*
Internet
Hospital Sign
Personal Recommendation from (Name)
I grant Arlington Cat Clinic permission to post my cat’s photo, and story on social media
Yes
No
If yes, (signature required)
*
Clear
PRE-EXAM QUESTIONNAIRE
Please make sure to complete this section before moving forward with the form. If yes to any of the following, please explain.
Is your cat currently taking any medications, flea preventative, heartworm preventative or food supplements?
Yes
No
If yes, please explain?
Any changes in your cat’s attitude or activity level?
Yes
No
If yes, please explain?
Any changes in how much your cat eats or drinks?
Yes
No
If yes, please explain?
Any problems with coughing, sneezing, or breathing?
Yes
No
If yes, please explain?
Any problems with the eyes, ears or nose?
Yes
No
If yes, please explain?
Any hair loss, sores, lumps, scratching or other skin problems?
Yes
No
If yes, please explain?
Any problems with vomiting?
Yes
No
If yes, please explain?
Any problems with diarrhea?
Yes
No
If yes, please explain?
Any problems with hard or dry stools?
Yes
No
If yes, please explain?
Any changes in the amount of urine or stool?
Yes
No
If yes, please explain?
Does your cat ever urinate or defecate outside the litter box?
Yes
No
If yes, please explain?
Does your cat have a hard time jumping or climbing the stairs?
Yes
No
If yes, please explain?
Do you have any questions or concerns today that are not covered above.
PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE RENDERED
In admitting my pet(s) for diagnostics, treatment, or surgery, I authorize the doctors of Arlington Cat Clinic, Ltd. and their support staff, to administer such treatment and /or perform such diagnostic or surgical procedures as deemed necessary. It is understood that an estimate of charges will be given for hospitalizations and surgeries. No guarantee or assurance can be made as to the results that may be obtained. Further, I realize that these charges may exceed a given estimate if complications arise. I understand that I will be contacted prior to treatment, if possible. I agree to pay Arlington Cat Clinic, Ltd. at the time services are rendered. If the account goes delinquent; no payment in 30 days, the account will be assessed a 2.00% billing fee on the outstanding balance (24% yearly). I further agree if the account is transferred to collections, I will be responsible for all the costs necessary to collect this balance including collection fees, costs, and filing fees. If a check is returned non-sufficient funds, a minimum of $25.00 will be added to the amount owed.
Signature
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