New Client Registration Form
Please fill out this form in its entirety and submit it no later than 24 hours prior to your appointment. If this form is not received at least 24 hours prior to the appointment, your appointment will be released to another patient in need.
Client Details:
Full Name
*
First Name
Last Name
Mailing address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Is this a home or cell phone?
*
Home
Cell
Cell Phone Number
If different from Primary
E-mail
example@example.com
Can we send you texts?
*
Yes
No
Can we send you emails?
Yes
No
Appointment reminders only
Preferred contact method
*
Please Select
Phone call
Text
Email
Is there another phone number we should have for the account?
*
Yes
No
Phone Number
Please enter a valid phone number.
Name (Last, First)
Please enter the name associated with the additional phone number.
Relationship to primary
How did you hear about us?
Please Select
Facebook
Instagram
Internet search
Personal Recommendation
Catoosa County Animal Shelter
Drove by
Other
Please Specify
Is it okay for us to use pictures and/or videos of your pet(s) on our social media?
*
Yes
No
Patient Details:
Please submit information for only the pet(s) we currently have scheduled for an appointment.
Patient Name
*
Species
*
Please Select
Canine (Dog)
Feline (Cat)
Breed
*
Please provide to the best of your knowledge - if your dog is an unknown mix, give us your best guess (i.e. what breed does your dog look most like, plus "mix"). Cats are typically classified as DSH (short haired), DMH (medium haired) and DLH (long haired) unless they are a specific pedigreed breed.
Color(s)
*
Date of birth (or approximate age)
*
Sex
*
Please Select
Male
Female
Male Neutered
Female Spayed
Unknown
Microchip/Tattoo number
Does your pet have any known allergies or reactions to vaccinations or medications?
*
Yes
No
Please explain
Has your pet ever been to the veterinarian before?
*
Yes
No
Name/location of previous veterinarian(s)
*
If the pet might be under a different owner or pet name, please list below
Has your pet ever had to be muzzled or medicated for examination or treatment?
*
Yes
No
Please explain
Do you have another pet to add?
*
Yes
No
Patient Name
*
Species
*
Please Select
Canine (Dog)
Feline (Cat)
Breed
*
Please provide to the best of your knowledge - if your dog is an unknown mix, give us your best guess (i.e. what breed does your dog look most like, plus "mix"). Cats are typically classified as DSH (short haired), DMH (medium haired) and DLH (long haired) unless they are a specific pedigreed breed.
Color(s)
*
Date of birth (or approximate age)
*
Sex
*
Please Select
Male
Female
Male Neutered
Female Spayed
Unknown
Microchip/Tattoo number
Does your pet have any known allergies or reactions to vaccinations or medications?
*
Yes
No
Please explain
Has your pet ever been to the veterinarian before?
*
Yes
No
Name/location of previous veterinarian(s)
*
If the pet might be under a different owner or pet name, please list below
Has your pet ever had to be muzzled or medicated for examination or treatment?
*
Yes
No
Please explain
Do you have another pet to add?
*
Yes
No
Patient Details:
Please submit information for only the pet(s) we currently have scheduled for an appointment.
Patient Name
*
Species
*
Please Select
Canine (Dog)
Feline (Cat)
Breed
*
Please provide to the best of your knowledge - if your dog is an unknown mix, give us your best guess (i.e. what breed does your dog look most like, plus "mix"). Cats are typically classified as DSH (short haired), DMH (medium haired) and DLH (long haired) unless they are a specific pedigreed breed.
Color(s)
*
Date of birth (or approximate age)
*
Sex
*
Please Select
Male
Female
Male Neutered
Female Spayed
Unknown
Microchip/Tattoo number
Does your pet have any known allergies or reactions to vaccinations or medications?
*
Yes
No
Please explain
Has your pet ever been to the veterinarian before?
*
Yes
No
Name/location of previous veterinarian(s)
*
If the pet might be under a different owner or pet name, please list below
Has your pet ever had to be muzzled or medicated for examination or treatment?
*
Yes
No
Please explain
Submit
Should be Empty: