South Putnam Animal Hospital - Pet Registration Form

Pet Registration Form
Client Name*

First NameLast Name
Home Phone Number*
Please enter a valid phone number.
Pet's Name*
Pet's Birth Date or Age*
Species*

CanineFelineFerretRabbitRodent (Hamster, Guinea Pig)
Breed*
Color*
Sex*

FemaleMale
Spayed/Neutered*

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

YesNo
This pet was obtained from a*

Pet ShopShelterBreederOther
Is this a stray animal?*

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

YesNo
If you have additional pets, list the type and number you have of each (e.g. dogs - 2, cats - 1, guinea pigs - 3).*
When were your pet's last vaccines given?*
Dog Medical History Section
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/Bordetella)
Leptospirosis
Rabies - Indicate 1 year or 3 year
Heartworm Blood Test
Is your dog on heartworm preventative?*

YesNo
Please list the type of heartworm prevention your dog is on (if you know).
Cat Medical History Section
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 our cat allowed to go outdoors?*

YesNo
If yes, please provide details about their outdoor privileges.*
Medical History For Your Pet List Above
Is your pet on medication at this time?*

NoYes
What medication and what condition is being treated?*
If known, what was the date your pet was dewormed for parasites, and what medication was used?
Dates and types of surgeries your pet has had:
Any adverse reactions to prior medications/vaccinations/treatments?*

NoYesUnknown (new pet)
If yes, please provide details:*
Why is your pet being seen today?*
Has your pet ever had this issue before?*

NoYes
Is yes, when?*
Payment
What form of payment will you be using?*

CashCheckVisa/MastercardCareCreditDiscoverAMEX
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:

Pet Registration Form

For New Pet Owners

Additional Pet Questions

Dog Medical History Section

Cat Medical History Section

Medical History For Your Pet List Above

Payment