New Client Registration Step 1 of 333%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 NameAddress* 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 Email AddressHome NumberWork NumberCell Number*Co-Owner Work NumberCo-Owner Cell NumberName of Previous ClinicEmergency Contact Name*Emergency Contact Phone*How did you learn about our clinic?*FacebookSignWebsiteRecommendationRecommended By Whom?Do you want to receive our monthly coupon and article by email?*YesNoCan we use a photo of your pet in marketing materials?*YesNoPET HEALTHSelect One:*DogCatPet Information*NameBreedDate of BirthColorSexSpayed or NeuteredCurrent on vaccines?*YesNoPet’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 OtherOtherAUTHORIZATIONI 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 SignatureCommentsThis field is for validation purposes and should be left unchanged.
