NEW CLIENT REGISTATION FORM

Date: ___________

Name: ____________________________________            Driver's License #: _____________________

Spouse (If Applicable): _______________________            Driver's License #: _____________________

Address: ____________________________________       Home Phone #: ________________________

                 Street                                              Apt#              Cell Phone #: _________________________

                                                                                              Work #:________I______________________

               ____________________________________       Spouse Cell # _________________________

                 City                    State                          Zip

Employer's Name: ____________________________   Spouse's Employer's Name _________________

Employer's Address: __________________________   Spouse's Employer's Address: ______________

PET INFORMATION

Pet's Name: ______________ Feline/ Canine/ Other: _____________ Last known weight: ____________

Breed: ___________________ Color: __________________________ Date of Birth: ________________

(Circle One)             Male                    Neutered Male                     Female                   Spayed Female

Date of Last Vaccinations: ___________________  Date of Last Heartworm Test: __________________

Date of Last Deworming: ____________________  On Heartworm Preventative?       YES     NO

If on heartworm prevention, what brand and when last dipsensed? _______________________________

Is your pet microchipped?     YES     NO        

What are you feeding your pet currently? ___________________________________________________

Has your pet been treated for any illness in the past year?   YES     NO

If yes, please explain:__________________________________________________________________

Previous Veterinarian:__________________________________________________________________

Reason for Visit today:_____________________________________________________________________________

Any additional information we need to know about your pet?:__________________________________

How did you hear about us? (Yellow pages--if so, which one? Drive by--Sign? Friend/Neighbor? Internet? __________________________________________________________________________

( If referred by another client please list their name)

I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges are to be paid at the time of service or release of my pet and that a deposit may be required prior to treatment.

(A service charge of 1.5 % per month. 18% APR will be added to all overdue accounts. Also liable for all legal and collection fees. )

Owner or responsible party (please sign) ___________________________________________________

Please provide the receptionist with your driver's license so a copy can be made for our files. Thank You!