New Client Registration Form-Bayshorevet

New Client Registration Form

First Name

Last Name

Address

Phone Number

Social Security Number OR Drivers License Number

Employer

Spouse's Name

Emergency Contact

Emergency Contact Phone Number

ALL FEES ARE DUE IN FULL AT THE TIME SERVICES ARE RENDERED

Please indicate your method(s) of payment. You may select 1 or more options.

Cash

Check

Visa

MasterCard

Discover

CareCredit

How did you learn of our clinic?

Yellow Pages

Online

Sign

Referral or Recommendation

If referred or recommended, who may we thank?

Please enter the following information for your pet.

Pet's Name

Species

Feline

Canine

Other (Please Specify)

If Species selected is "Other," please specify

Breed

Color/Markings

Pet's Date of Birth

Pet's Sex

Female (Intact)

Male (Intact)

Female (Spayed)

Male (Neutered)

Microchip Number (If no MC, type NONE):

VACCINATION HISTORY

Please provide the dates the vaccines were LAST GIVEN.

Vaccination History: Last Given Date of Rabies

Vaccination History: Last Given Date of DHPP (dogs) or FVRCP (cats)

Vaccination History: Last Given Date of Leptospirosis Vaccine (dogs only)

Vaccination History: Last Given Date of Lyme Vaccine (dogs only)

Vaccination History: Last Given Date of Bordetella (Kennel Cough) Vaccine (dogs only)

Vaccination History: Last Given Date of Feline Leukemia Vaccine (cats only)

History: Date of Last Heartworm Test

In detail, please describe your pet's diet:

Please list any medications and supplements your pet receives, including preventatives.

Please list any previous illnesses or surgeries your pet has experienced.

What are your current primary concerns for your pet?

Please upload a photo of your pet's history here.

OR: Please upload a document file of your pet's history here.

AUTHORIZATION

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid in full at the time of release and that a deposit may be required for surgical treatment.

Your Signature

Date