"
*
" indicates required fields
Step
1
of
3
33%
Client Information
Owner Name
*
Owner Phone
*
Co-Owner Name
Co-Owner Phone
Address
*
Street Address
City
ZIP / Postal Code
Email Address
*
Employer
Occupation
How did you hear about us?
*
Patient Information
Name
*
Breed
*
Color
Species
*
Canine
Feline
Other
Sex
*
Female
Female Spayed
Male
Male Neutered
DOB / Age
*
Last Date Vaccinated
*
Previous Vet
*
Has your pet ever had an allergic reaction to vaccines or medications?
*
Would you like to register another pet?
YES
NO
Name
*
Breed
*
Color
Species
*
Canine
Feline
Other
Sex
*
Female
Female Spayed
Male
Male Neutered
DOB / Age
*
Last Date Vaccinated
*
Previous Vet
*
Has your pet ever had an allergic reaction to vaccines or medications?
*
For marketing and educational purposes, I approve photos of my pet to be shared to social media
*
I authorize
I do not authorize
Video and audio recording is taken at all times in all exam rooms for educational and training purposes
Consent
*
I authorize
I authorize Wasatch Hollow Animal Hospital Veterinarians to examine,
prescribe for, or treat the above listed patient(s). I assume responsibility for all charges incurred in the
care of this/these animal(s) and understand that these charges will be paid at the time of service
rendered. Should collection become necessary, I agree to pay an additional 33.3% collection fee and all
legal fees of collection, with or without suit, including attorney fees and court fees.
I verify that I am the owner of the above stated pet(s) and am over the age of 18
Signature
Date
MM slash DD slash YYYY