Clayview Animal Clinic

50877 US 31 North

South Bend, In 46637

Patient Registry

Thank you for giving us the opportunity to care for your pet. Please help us meet your needs better by taking a moment to complete both pages of this information sheet.

Date: _______________

Owner's Name ______________________   Birth Date _____________  S.S # _____________

Spouse/ Other ______________________  Birth Date _____________  S.S # _____________

Address ______________________________________________  E-mail _________________

City ___________________________________  State ________  Zip ____________________

Home __________________  Work __________________  Cell Number ___________________

Employer's Name and Address_____________________________________________________

Spouse's/ Other's Employer & Address______________________________________________

At what time _________ and at what number _______________ is the best time to call you?

In case of emergency, please call ___________________ at the number ________________.

We will gladly prepare a written estimate if you desire. Please ask the receptionist or assistant. Professional fees are due at the time services are rendered. If you pay by check, please complete the following:

In the event of any default, the customer shall be responsible for all cost of collection, damages, and expenses including actual attorney fees.

Driver's License State ______  Driver's License Number________________________________

Signature______________________________________________________________________

How did you hear of our hospital?__________________________________________________

To prevent the spread of infectious diseases and parasites, hospitalized and boarded animals must be current on all vaccinations and free of internal parasites and external parasites. I authorize the doctor to provide vaccinations and parasite control as needed for my pet.