New Patient - Client form REGISTRATION Owner * First Name Last Name Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country How did you learn about our clinic? Sign Outside Website Yellow Pages Newspaper Facebook Recommendation Other PET HEALTH HISTORY Pet's Name * Species * Sex * Breed * Color * Birthdate MM DD YYYY AUTHORIZATION Checkbox * I hereby authorize the veterinarian to examine, prescribe for, and/or treat the above described pet. I assume full responsibility for all charges incurred for 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. Media Use Consent * I do I do not authorize the use of my pet's name and photograph and/or video footage to be used in veterinary-related publications including those in traditional and internet media such as social networking, newspaper, TV spots and web sites. Thank you!
