Form - New Client Registration Form

Welcome
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 this form. We also have this form available for you to fill out in the office for your convenience.
Owner's Name (required)
First Name (required)
Last Name (required)
Owner's Birth Date and Social Security Number (required)

Spouse's Name
First Name
Last Name
Spouse's/ Other's Birth Date and Social Security Number

Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
E-Mail Address (required) :
Phone (required)
Phone TypePhone Number (required)
Phone (required)
Phone TypePhone Number (required)
Phone (required)
Phone TypePhone Number (required)
Employer's Name and Address (required)

Spouse's/ Other's Employer and Address (required)

At what time and phone number is best to call about your pet? (required)

Who should we contact in case of emergency and at what phone number? (required)

We will gladly prepare a written estimate if you desire.
Please ask the receptionist or doctor. 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's fees.
Driver's License State and Number (required)

Electronic Signature and Date (required)

How did you first hear about our hospital? (required)
a AAHA Referal
b Individual; someone we may thank?
c Hospital sign
d Yellow pages
e Other
If you marked individual or other, please elaborate.

To prevent the spread of infectious diseases and parasites
hospitalized and boarded animals must be current on all vaccines and free of internal and external parasites. I authorize the doctor to provide vaccines and parasite control as needed for my pet.
Animals' Name (you can list multiple pets if needed) (required)

Species, Breed, and Description (Color) (required)

Age or date of birth (required)

Sex, Spayed/ Neutered? (required)

What type of vitamins, treats, and food do you give your pet? (required)

Types of grooming products? (required)

Hours spent outdoors each day? (required)

What vaccinations has your pet had? (required)

When has your pet been heartworm tested? What type of heartworm prevention is your pet on? (required)

Has your pet had a fecal or stool test recently, if so when and result? Has your pet been dewormed? (required)

Has your pet had any previous dentistry, if so when? (required)

Has your pet had any prior illness or surgery? (required)

Where did you get your pet? (Humane society, pet shop, kennel, friend, or stray) (required)