Animal Medical Clinic- New Patient Registration Form

Step 1 of 32

REGISTRATION

Owner(Required)

Street Address(Required)

State(Required)

City(Required)

Zipcode(Required)

Cell phone(Required)

Email(Required)

Additional Contact (In Case Of Emergency)

Emergency Contact Name(Required)

Home Phone(Required)

Cell Phone(Required)

How did you learn of our clinic?

Yellow Pages

Recommendation

Sign/Location

Facebook

Google

Other

Hidden

Number of pets:

Number of pets:

Dogs(Required)

Cats(Required)

Other (Specify)(Required)

Which Social media platforms do you use? (Check any that apply)

Facebook

Twitter

Instagram

Google Plus

Other

Preferred method of contact:(Required)

Phone

Text Message

How would you prefer to receive exam & vaccine reminders?(Required)

Postcard

Text Message

Phone call

PET HEALTH HISTORY

Name of pet(Required)

Species(Required)

Dog

Cat

Other

Breed(Required)

Color(Required)

Birthdate(Required)

MM slash DD slash YYYY

Male Neutered | Female Spayed(Required)

Male

Neutered

Female

Spayed

Male Neutered | Female Spayed

Does your pet have a microchip?(Required)

Yes

Chip No.(Required)

Vaccination History (Date and type of last vaccinations)(Required)

Pet’s current medications(Required)

Allergies(Required)

Describe your pet’s diet(Required)

Describe known medical issues(Required)

Do you want to add another pet?(Required)

Yes

PET HEALTH HISTORY

Name of pet(Required)

Species(Required)

Dog

Cat

Other

Breed(Required)

Color(Required)

Birthdate(Required)

MM slash DD slash YYYY

Male Neutered | Female Spayed(Required)

Male

Neutered

Female

Spayed

Male Neutered | Female Spayed

Does your pet have a microchip?(Required)

Yes

Chip No.(Required)

Vaccination History (Date and type of last vaccinations)(Required)

Pet’s current medications(Required)

Allergies(Required)

Describe your pet’s diet(Required)

Describe known medical issues(Required)

Do you want to add another pet?(Required)

Yes

PET HEALTH HISTORY

Name of pet(Required)

Species(Required)

Dog

Cat

Other

Breed(Required)

Color(Required)

Birthdate(Required)

MM slash DD slash YYYY

Male Neutered | Female Spayed(Required)

Male

Neutered

Female

Spayed

Male Neutered | Female Spayed

Does your pet have a microchip?(Required)

Yes

Chip No.(Required)

Vaccination History (Date and type of last vaccinations)(Required)

Pet’s current medications(Required)

Allergies(Required)

Describe your pet’s diet(Required)

Describe known medical issues(Required)

Do you want to add another pet?(Required)

Yes

PET HEALTH HISTORY

Name of pet(Required)

Species(Required)

Dog

Cat

Other

Breed(Required)

Color(Required)

Birthdate(Required)

MM slash DD slash YYYY

Male Neutered | Female Spayed(Required)

Male

Neutered

Female

Spayed

Male Neutered | Female Spayed

Does your pet have a microchip?(Required)

Yes

Chip No.(Required)

Vaccination History (Date and type of last vaccinations)(Required)

Pet’s current medications(Required)

Allergies(Required)

Describe your pet’s diet(Required)

Describe known medical issues(Required)

Do you want to add another pet?(Required)

Yes

PET HEALTH HISTORY

Name of pet(Required)

Species(Required)

Dog

Cat

Other

Breed(Required)

Color(Required)

Birthdate(Required)

MM slash DD slash YYYY

Male Neutered | Female Spayed(Required)

Male

Neutered

Female

Spayed

Male Neutered | Female Spayed

Does your pet have a microchip?(Required)

Yes

Chip No.(Required)

Vaccination History (Date and type of last vaccinations)(Required)

Pet’s current medications(Required)

Allergies(Required)

Describe your pet’s diet(Required)

Describe known medical issues(Required)

Do you want to add another pet?(Required)

Yes

PET HEALTH HISTORY

Name of pet(Required)

Species(Required)

Dog

Cat

Other

Breed(Required)

Color(Required)

Birthdate(Required)

MM slash DD slash YYYY

Male Neutered | Female Spayed(Required)

Male

Neutered

Female

Spayed

Male Neutered | Female Spayed

Does your pet have a microchip?(Required)

Yes

Chip No.(Required)

Vaccination History (Date and type of last vaccinations)(Required)

Pet’s current medications(Required)

Allergies(Required)

Describe your pet’s diet(Required)

Describe known medical issues(Required)

Do you want to add another pet?(Required)

Yes

PET HEALTH HISTORY

Name of pet(Required)

Species(Required)

Dog

Cat

Other

Breed(Required)

Color(Required)

Birthdate(Required)

MM slash DD slash YYYY

Male Neutered | Female Spayed(Required)

Male

Neutered

Female

Spayed

Male Neutered | Female Spayed

Does your pet have a microchip?(Required)

Yes

Chip No.(Required)

Vaccination History (Date and type of last vaccinations)(Required)

Pet’s current medications(Required)

Allergies(Required)

Describe your pet’s diet(Required)

Describe known medical issues(Required)

Do you want to add another pet?(Required)

Yes

PET HEALTH HISTORY

Name of pet(Required)

Species(Required)

Dog

Cat

Other

Breed(Required)

Color(Required)

Birthdate(Required)

MM slash DD slash YYYY

Male Neutered | Female Spayed(Required)

Male

Neutered

Female

Spayed

Male Neutered | Female Spayed

Does your pet have a microchip?(Required)

Yes

Chip No.(Required)

Vaccination History (Date and type of last vaccinations)(Required)

Pet’s current medications(Required)

Allergies(Required)

Describe your pet’s diet(Required)

Describe known medical issues(Required)

Do you want to add another pet?(Required)

Yes

PET HEALTH HISTORY

Name of pet(Required)

Species(Required)

Dog

Cat

Other

Breed(Required)

Color(Required)

Birthdate(Required)

MM slash DD slash YYYY

Male Neutered | Female Spayed(Required)

Male

Neutered

Female

Spayed

Male Neutered | Female Spayed

Does your pet have a microchip?(Required)

Yes

Chip No.(Required)

Vaccination History (Date and type of last vaccinations)(Required)

Pet’s current medications(Required)

Allergies(Required)

Describe your pet’s diet(Required)

Describe known medical issues(Required)

Do you want to add another pet?(Required)

Yes

PET HEALTH HISTORY

Name of pet(Required)

Species(Required)

Dog

Cat

Other

Breed(Required)

Color(Required)

Birthdate(Required)

MM slash DD slash YYYY

Male Neutered | Female Spayed(Required)

Male

Neutered

Female

Spayed

Male Neutered | Female Spayed

Does your pet have a microchip?(Required)

Yes

Chip No.(Required)

Vaccination History (Date and type of last vaccinations)(Required)

Pet’s current medications(Required)

Allergies(Required)

Describe your pet’s diet(Required)

Describe known medical issues(Required)

AUTHORIZATION

1) Photo Consent:

We love social media! Do we have your permission to share your pet(s)’ image and story on social media, our website & other forms of related media? Your name and personal information will never be shared. Simply check below to authorize this:(Required)

Yes. I authorize you to share my pet’s photo & story.

No. I do not authorize this.

2) Treatment Consent:

I hereby authorize the veterinarian to examine, prescribe for, or treat above described pet(s). I assume responsibility for all charges incurred in the care of this animal. I also understand that payment is always due IN FULL at the time of service. I recognize that financial concerns should be discussed PRIOR to exam and treatment. The staff is happy to provide estimates. Deposit may be required.

Signature(Required)

Date(Required)

MM slash DD slash YYYY