CLIENT
REGISTRATION
Owner’s Name:
Last_______________________________ First_________________________
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
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