Arlington Cat Clinic – Registration Form

New Patient Registration Form
What day and time is your appointment?*

MonthDayYear
Date
Hour MinutesAM/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*

MonthDayYear
Date
Co-Owner Date of Birth*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCounty
For check writing privileges, please provide your driver’s license # *
Pet Information
Pet Name
Sex
Spayed or Neutered?
Date of Birth or Age
Breed
Color
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?*
Does your cat go outside?*
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 petA member of the family
How did you become aware of us?*

InternetHospital SignPersonal Recommendation from (Name)
I grant Arlington Cat Clinic permission to post my cat’s photo, and story on social media

YesNo
If yes, (signature required)*

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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?

YesNo
If yes, please explain?
Any changes in your cat’s attitude or activity level?

YesNo
If yes, please explain?
Any changes in how much your cat eats or drinks?

YesNo
If yes, please explain?
Any problems with coughing, sneezing, or breathing?

YesNo
If yes, please explain?
Any problems with the eyes, ears or nose?

YesNo
If yes, please explain?
Any hair loss, sores, lumps, scratching or other skin problems?

YesNo
If yes, please explain?
Any problems with vomiting?

YesNo
If yes, please explain?
Any problems with diarrhea?

YesNo
If yes, please explain?
Any problems with hard or dry stools?

YesNo
If yes, please explain?
Any changes in the amount of urine or stool?

YesNo
If yes, please explain?
Does your cat ever urinate or defecate outside the litter box?

YesNo
If yes, please explain?
Does your cat have a hard time jumping or climbing the stairs?

YesNo
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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