New Client Registration Step 1 of 3 33% REGISTRATIONThank you for giving us the opportunity to serve you and your pet. Dr. Alex and his team will be happy to answer any questions you have about your pet’s health today. To ensure the best care possible, please take the time to fill out this form completely. Owner Name* Co-Owner Name Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address Home Number Work Number Cell Number* Co-Owner Work Number Co-Owner Cell Number Name of Previous Clinic Emergency Contact Name* Emergency Contact Phone*How did you learn about our clinic?* Facebook Sign Website Recommendation Recommended By Whom? Can we communicate with you via text in regards to your pet when needed?* Yes No Can we use a photo of your pet in marketing materials?* Yes No PET HEALTHSelect One:* Dog Cat Pet Information*NameBreedDate of BirthColorSexSpayed or NeuteredCurrent on vaccines?* Yes No Pet’s current medicationsReason for visit*Other Issues Behavior Problems Breathing Problems Third Choice Coughing Diarrhea Ear Issues Gagging Lack of Appetite Weakness Vomiting Limping Loss of balance Scooting Scratching Seems Depressed Shaking Head Eye bulging or bloodshot Sneezing Thirst and/or Urination Increased Other Other AUTHORIZATIONI 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 services are rendered and that a deposit may be required for surgical treatment.Type Signature CAPTCHAHave you scheduled your pet’s appointment with clinic yet?* Yes No If you select no, someone from our staff will reach out to you to schedule your first appointment. Date of appointment* MM slash DD slash YYYY Time of appointment* : Hours Minutes AM PM AM/PM CommentsThis field is for validation purposes and should be left unchanged.
