New Client Registration FormThank you for giving us the opportunity to care for your pet. We’ll be happy to answer any questions you have about your pet’s health. To insure the best care possible, please take the time to fill in this form completely. Thank you!RegistrationOwner*Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code SpouseHome PhoneWork PhoneCell Phone*Spouse Work PhoneSpouse Cell PhoneEmail* Emergency Contact Name First Last Emergency Contact PhoneHow did you learn of our clinic?Yellow PagesRecommendationSignIf recommended, by whom?Number of pets:DogsCatsOther (specify) Reason for visitPet Health HistoryName of petSpeciesDogCatBreedColorBirthdateVaccination History (Date and type of last vaccinations)Please check (4) any symptoms or problems that you have noticed about your pet. Behavior Problems Bleeding Gums Breathing Problems Coughing Diarrhea Eye Bulging or Bloodshot Gagging Lack of Appetite Limping Loss of Balance Scooting Scratching Seems Depressed Shaking Head Sneezing Thirst and/or Urination Increaed Vomiting Weakness OtherPlease describePet’s current medicationsDescribe your pet’s dietAuthorizationI 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 at the time of release and that a deposit may be required for surgical treatment.Signature of OwnerType your name in full aboveDateNameThis field is for validation purposes and should be left unchanged.