New Patient – Client form REGISTRATIONOwner(Required) First Last Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City State ZIP / Postal Code How did you learn about our clinic? Sign Outside Website Yellow Pages Newspaper Facebook Recommendation Other PET HEALTH HISTORYPet's Name(Required) Species(Required) Sex(Required) Breed(Required) Color(Required) BIrhtdate MM slash DD slash YYYY AUTHORIZATIONMedical(Required) 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(Required) 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.
