Island Life Animal Hospital Registration Form

Island Life Animal Hospital

New Client Form
Welcome to Island Life Animal Hospital, Please take a moment to complete this form for our records.
OWNER
CoOwnerSpouse
ADDRESS
APT
CITY
STATE
ZIP
HOME #
CELL #
WORK #
Preferred number if different from above
EMAIL
example@example.com
May we communicate with you via text message
*Emails are utilized for reminders and hospital communications only*
Please let us know how you heard about our clinic
Referred by a friend? Tell us who
Previous Vet Clinic where records may be located
Name of Pet Insurance if applicable
Preferred outside Pharmacy for your Pets if applicable
PET 1 NAME
Sex
Species
BREED
COLOR
BIRTH DATE or Estimated Age

MonthDayYear
Date
Does your pet have a microchip?
Has your pet had a rabies vaccination?
Last date of Rabies if known

MonthDayYear
Date
Is your pet currently on any medications? If so which ones
Is your pet currently on any Heartworm and Flea Prevention? Which one(s)?
Does this pet have any known anxieties/stress triggers?
Does this pet have any known allergies or reactions to medications or vaccines?
PET 2 NAME
Sex
Species
Breed
COLOR
BIRTH DATE or Estimated Age

MonthDayYear
Date
Does your pet have a microchip
Has you pet had a rabies vaccination?
Last Date of Rabies if known

MonthDayYear
Date
Is your pet currently on any medications? If so please list
Is your pet currently on any HeartWorm and Flea Prevention? If so, which one(s)
Does this pet have any known anxieties/stress triggers, if so what are they?
Does this pet have any known allergies or reactions to medications or vaccines? If so what are they?
By signing this form I authorize the taking of photographs of my pets by the staff of Island Life Animal Hospital for the purpose of posting on Facebook, the ILAH website, and other online sites used for the professional and promotional purposes by Island Life Animal Hospital. The photos will remain the property of Island Life Animal Hospital and will be made available to the owner upon request at the discretion of management.
Signature
Date

MonthDayYear
Date
As the rightful owner of the above described pet, I hereby authorize the veterinary medical staff of Island Life Animal Hospital to examine, prescribe for, and treat said pet. / assume all responsibility for the charges incurred associated with these services. A treatment plan and financial estimate for recommended services will be provided for all hospitalized pets and upon request at any time. / understand that all charges are to be paid when services are rendered and that a deposit may be required
Signature
Date

MonthDayYear
Date
*Payment is due when services are rendered* We accept the following forms of payment: Visa, MasterCard, Discover, American Express and cash. Additional Options are Care Credit, which provides interest-free payment options, and ScratchPay provides simple payment plans for medical financing.
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