Welcome 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 ensure the best care possible, please take the time to fill in this form completely. Thank you! REGISTRATION Date MM slash DD slash YYYY Owner's Name Spouse/Other Address Street Address City State / Province / Region ZIP / Postal Code Home PhoneWork PhoneCell PhoneEmail Driver's License #................................ (if paying by check) Employer's Name & Address Email Address: In Case of EMERGENCY, Please CallPlease Describe Other Animals in Household Reason for Visit PET HEALTH HISTORYPet's Name Age Date of Birth MM slash DD slash YYYY Type of Animal Dog Cat Other explain other Sex Male Neutered Female Spayed Breed Color Vaccination History (date and type of last vaccination) Please list any symptoms or problem that you have noticed about your petCurrent Medications Describe Your Pet's Diet Authorization I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I understand that these charges must be paid at the time of release and that a deposit may be required for surgical and medical treatment. Signature of Owner/ AgentDate MM slash DD slash YYYY
