CLIENT REGISTRATION

Owner’s Name: Last_______________________________ First_________________________ SS#___________________

Address ____________________________________ City_______________________ State________ Zip_________

Home # _______________________ Cell or Pager #__________________ Employer______________ Work #__________

Spouse’s Name_______________________ Spouse’s Employer______________________ Work #__________________

How did you learn of our hospital?

£ Yellow Pages £ Hospital Sign

£ Website £ Recommendation If so, who may we thank? ___________________

PET INFORMATION

Name of Pet________________________

£ Dog £ Cat £ Other _____________ £ Male £ Neutered

£ Female £ Spayed

Breed__________________________ Color____________________

Birth Date___________________

Vaccination History (Date and type of last vaccinations) _____________________________________________

Please check any symptoms or problems that you have noticed about your pet:

£ Behavior Problems £ Lack of Appetite £ Sneezing £ Bleeding Gums

£ Limping £ Breathing Problems £ Loss of Balance £ Vomiting

£ Coughing £ Scooting £ Weakness £ Diarrhea

£ Scratching £ Gagging £ Depressed £ Shaking Head

£ Eyes Bulging/Bloodshot £ Thirst and/or Frequent Urination

Other: ____________________________________________________________________________________________

Pet’s Current Medications: __________________________________________________________________________

Describe your pet’s diet_____________________________________________________________________________

AUTHORIZATION

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume full

responsibility for all charges incurred in the care of this animal. I also understand that these charges incurred

will be paid at the time services are rendered.

Signature of Owner_______________________________________________ Date __________________

Method of Payment: £ Cash £ Check £ Mastercard £ Visa

Mt. Tabor Animal Hospital

Vaccination Assessment

At Mt. Tabor we want to administer only the vaccines that are needed for your pet’s health. We need to ask a few questions to help assess the disease risk for your pet. A vaccination protocol will be customized for each pet’s needs.

Name of pet: ________________________

Age of pet: ________________________

1. When your pet goes outdoors, is he/she ever unsupervised? Y N

2. Does your pet come into contact with other pets or their environments? Y N

3. Is there wildlife in your area with which your pet may come into contact? Y N

4. Is your pet exposed to ticks? Y N

5. Do you travel with your pet north of Richmond, Virginia? Y N

6. Does your pet have an opportunity to drink from standing water outdoors? Y N

7. Do you take your pet to a groomer or boarding facility? Y N

8. Do you take your pet to dog or cat shows? Y N

9. If you own a dog, do you ever take him/her hunting? Y N

10. Is your pet spayed or neutered? Y N

11. a. If you own a dog, is he/she on monthly heartworm preventative? Y N

b. Have you missed a dose by more than two weeks? Y N

Thanks! These answers will help us recommend which vaccinations are needed for your pet.

For Office Use Only

Canine Feline

Rabies 1yr 3yr Rabies (Purevax 1year)

Distemper/Parvovirus 1yr 3yr Rhino/Calici/Panleukopenia 1yr 3yr

Bordetella 6mo 1yr Leukemia

Leptospirosis FIV

Lyme