Thank you for giving us the opportunity to care for your pet. We’ll be happy to answer any questions you have about your pet’s health. To insure the best care possible, please take the time to fill in this form completely.

REGISTRATION

Owner:
Address
Spouse
E-mail Address *
Home Phone
Work Phone:
Spouse Phone
Emergency Contact Name:
How did you learn of our clinic?
Sign
Yellow Pages
Recommendation
Other
If recommended by whom?

Number of pets:

Dogs:
Cats
Other(Specify)
Reason for visit:

PET HEALTH HISTORY

Name of Pet:
Dog
Cat
Other
Specify:
Breed
Color
Birth date:
Male
Neutered
Female
Spayed
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
Thirst and/or Urination increased
Coughing
Scooting
Weakness
Gagging
Shaking head
Diarrhea
Scratching
Seems Depressed
Eye Bulging or Bloodshot
Other
Pet’s Current Medication:
Describe your pet’s diet:
Authorization*
I hereby authorize the veterinarian to examine, prescribe for, or treat the above pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment.
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ISN'T IT TIME FOR YOUR DOG TO FEEL LIKE A DOG AGAIN?