South Putnam Animal Hospital - Client Registration Form

Client Registration Form
Client Information
Name*

First NameLast Name
Home Telephone #
Please enter a valid phone number.
Work Telephone #
Please enter a valid phone number.
Cell Phone #*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse/Co-Owner Name

First NameLast Name
Spouse/Co-Owner Work Telephone #
Please enter a valid phone number.
Spouse/Co-Owner Cell Phone #
Please enter a valid phone number.
Client Email Address*
example@example.com
Are you a senior citizen?

YesNo
IN THE CASE OF EMERGENCY

and no one is reachable at the above numbers, please contact:
Name*

First NameLast Name
Telephone*
Please enter a valid phone number.
Referral Information
How did you hear about us?*

FriendWebsite/InternetFacebookYelpPrevious ClientSigns/Hospital LoationAnimal Welfare LeagueProfessional ReferralVerizon Yellow Page
Name of Referral
Phone # of Referral (if applicable)
Please enter a valid phone number.
Pet Registration Form
Pet's Name*
Date/Year Born*
Species*

DogCatFerretRabbitRodent (Hamster, Guinea Pig)
Breed*
Description/Color*
Sex*

MaleFemale
Spayed/Neutered?*

YesNo
For New Pet Owners
Is this pet new to your home?*

YesNo
This pet was obtained from a*

Pet ShopShleterBreederOther
Is this a stray animal?*

YesNo
How long have you had this pet?*
Additional Information
Do you have any other pets?*

YesNo
How many dogs?
How many cats?
How many "other" pets?
Where were your pet's last vaccines given?*
For Dogs
Are you completing this form for your dog?*

YesNo
Please enter the date of your dog's last vaccination and test:
Distemper/Parvo
Lyme
Canine Cough (kennel cough)
Leptospirosis
Rabies - Indicate 1 year or 3 year
Heartworm Blood Test
Is your dog on heartworm prevention?*

YesNo
If yes, what type?
For Cats
Are you completing this form for your cat?*

YesNo
Please enter the date of your cat's last vaccination and test:
Feline Distemper/Respiratory Vaccines
Rabies - Indicate 1 year or 3 year
Feline Leukemia Virus Test
Feline Leukemia Vaccine
Is your cat allowed to go outdoors?*

YesNo
If yes, please provide details:
Additional Medical History for Your Pet
Dates and types of any past surgeries
Any adverse reactions to prior medications/vaccinations/treatments?*

YesNo
If yes, please provide details:*
Forms of Payment
What form of payment will you be using?*

AMEXDiscoverCareCreditVisa/MastercardCheckCash
Social Media Release
I hereby grant South Putnam Animal Hospital permission to use my testimonial or likeness in a photograph, video, or other digital media ("Photo") in any and all of its publications, including web-based publications, without payment or other consideration, for purposes of advertising the hospital staff or services.

I understand and agree that all photos will become the property of the South Putnam Animal Hospital and will not be returned.

I hereby irrevocably authorize South Putnam Animal Hospital to edit, alter, copy, exhibit, publish, or distribute any testimonial and Photo for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my testimonial or likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the testimonial or Photo.

I hereby hold harmless, release, and forever discharge the South Putnam Animal Hospital from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.
I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENT/GUARDIAN AS EVIDENCED BY THEIR SIGNATURE BELOW.*

I agreeI do NOT agree
(Owner) Parent or Guardian Name*

First NameLast Name
(Owner) Parent or Guardian Signature*
Today's Date*

MonthDayYear
Date
Authorization of Services: I, the undersigned owner, authorized agent of the owner, or Good Samaritan responsible for seeking veterinary care for the pet identified above, certify that I am over eighteen years of age, and hereby consent to the examination of this pet by staff veterinarians at this veterinary practice. I understand that an estimate of the costs for veterinary services is available and that I am encouraged to discuss all fees attendant to such care before services are rendered. I understand that payment is expected at time services are rendered and I assume all financial responsibility for all said services.
Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

Client Registration Form

Client Information

IN THE CASE OF EMERGENCY

Referral Information

Pet Registration Form

For New Pet Owners

Additional Information

For Dogs

For Cats

Additional Medical History for Your Pet

Forms of Payment

Social Media Release