Welcometo Animal Health Care Center
Thank you for giving us the opportunity to care for your pets. We will 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 out this form completely.
Registration |
Date:____________ |
|---|
Owner's Name:_______________________________________________ SS#:_______________________
Spouse/Co-Owner's Name:______________________________________ SS#:______________________
Address:_________________________________ City:__________________ State:_____ Zip:__________
Home Phone:______________ Work Phone:______________ Cell Phone:______________________
Employer's Name & Address:__________________________________________________________
Spouse/Co-Owner's Employer & Phone#:__________________________________________________
E-Mail Address:_______________________ How would you prefer to be notified of medical reminders? E-Mail / Mail / Both
Emergency Contact Name:________________________________ Phone#:_________________________
How did you learn of our clinic? 
Yellow Pages Website Sign Recommendation
Other:______________________ If recommended, whom may we thank? _________________________
Pet # 1 |
Pet # 2 |
|---|---|
Name______________________________________ Birth Date__________________________________ Species: Dog Cat Other:______________
Breed_________________________ Sex________ Color______________________________________ Neutered/Spayed?____________ Date__________ Vaccination History__________________________ ___________________________________________ Long Term Problems_________________________ ___________________________________________ Current Medications_________________________ Pet's Diet__________________________________ |
Name______________________________________ Birth Date__________________________________ Species: Dog & Cat Other:_______________
Breed__________________________ Sex_________ Color_______________________________________ Neutered/Spayed?______________ Date_________ Vaccination History___________________________ ____________________________________________ Long Term Problems__________________________ ____________________________________________ Current Medications__________________________ Pet's Diet___________________________________ |
Previous veterinarian(s) where past records can be obtained________________________________________
I hereby authorize Animal Health Care Center to examine, prescribe for and treat the pet(s) listed above. I assume responsibility for all charges incurred in the care of the animal(s). I also understand that these charges will be paid at the time of release and that a deposit may be required for treatment.
Signature of Owner or Responsible Party____________________________________ Date_____________
Payment: Cash Check Visa/MC Driver's License Number______________________ State___________