Client Registration Form Please Check One: New Client Current Client-New Pet Name First Middle Last Address Street Address City State / Province / Region ZIP / Postal Code Phone No.Email Emergency No.Employer Work PhoneSpouse or Co-Owner’s Name Employer Work PhoneHow did you first hear of us? (Person's Name, Yellow Pages, Sign, Newspaper, Other) PET NO. 1Name Birth Date MM slash DD slash YYYY Species: Cat Dog Other Explain Other: Breed Sex Neutered? Date MM slash DD slash YYYY Date Last Vaccination MM slash DD slash YYYY Last Rabies Vaccination Where Shots Obtained Any Long-Term ProblemsCurrent Medications, if any Add More PET NO. 2Name Birth Date MM slash DD slash YYYY Species: Cat Dog Other Explain Other: Breed Sex Neutered? Date MM slash DD slash YYYY Date Last Vaccination MM slash DD slash YYYY Last Rabies Vaccination Where Shots Obtained Any Long-Term ProblemsCurrent Medications, if anyReason for visit List names and types of any other pets you ownMethod of Payment: Cash Check MC/VISA Discover I hereby authorize the veterinarian to examine, prescribe for, or treat, the above described pet(s). 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.Signature of Owner or AgentDate MM slash DD slash YYYY
