Owner Name*

First Last

Co-Owner Name

First Last

Pet Name*

Pet Type*

Cat
Dog

Sex*

Male (neutered)
Female (spayed)
Male (intact)
Female (intact)

Breed*

Color*

Pet DOB or Approx. Age*

Last Rabies Vaccination*

Any Long Term Problems?

Please describe & indicate if listing multiple pets

Previous Records Available?*

Yes
No

Location of Previous Records

Please list contact information for previous records & indicate if listing multiple pets

Add a second pet?

Yes
No

2nd Pet's Name

First Last

2nd Pet Type

Cat
Dog

Sex

Male (neutered)
Female (spayed)
Male (intact)
Female (intact)

2nd Pet Breed

2nd Pet Color

2nd Pet DOB or Approx. Age

2nd Pet Last Rabies Vaccination

Add a third pet?

Yes
No

3rd Pet's Name

First Last

3rd Pet Type

Cat
Dog

Sex

Male (neutered)
Female (spayed)
Male (intact)
Female (intact)

3rd Pet Breed

3rd Pet Color

3rd Pet DOB or Approx. Age

3rd Pet Last Rabies Vaccination

Phone*

Email*

Physical Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Mailing Address Same as Physical

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

*

How did you hear about our clinic?

Website
Google
Facebook or Instagram
Friend or Family

Financial Agreement*

I am the owner of the animal or am responsible for it and have the authorization to execute this consent. I hereby authorize the treatment of this animal and performance of such medical, surgical, or therapeutic procedures you determine to be indicated and use of such anesthetics as you deem advisable. I understand that all professional fees are due at the time of service. It is agreed that past due accounts are subject to maximum allowed per month late charges, and in addition, all costs of collection including a reasonable attorney's fee.

I agree

Photo Consent*

I grant permission to use any photographs taken of myself or my pet, in any and all of its publications, including website and social media entries, without payment or any other consideration. I hereby authorize to edit, alter, copy, exhibit, publish or distribute this photo for purposes of publicizing your programs or for any other lawful purpose. In addition, I waive any right to royalties or other compensation arising or related to the use of the photograph. I hereby release rights to all claims, demands, and causes to action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf of my estate have or may have by reason of this authorization. In signing this consent, I give authorization to use my name and my pet’s name and information as printed below.

Yes
No

Signature*