New Client Registration Form

Step 1 of 7

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Owner's Information

Name*

First Last

Phone*

Work Phone

Email*

Confirm Email*

Address*

Street Address Address Line 2 City ZIP Code

Co-Owner's Information

Name

First Last

Phone

Work Phone

Please note: If you are providing this information, you are giving permission for us to contact you at work.

Preferred method of contact*

Phone

Text

Mail

Referral Information

How did you find out about our practice?

Clinic Location

Personal Referral

Internet Search / Website

Yellow Pages

Clinic Sign

Newspaper / Print Media

Other

If other, please specify

If Personal Referral, is there someone we can thank for this referral?

Please use this area to give us any other relevant information about yourself or your family

How many pets would you like to register today?*

One

Two

Three

Four

Pet Information - #1

Pet's Name*

Species*

If other species not listed above

Breed (If known)

Color

Date of Birth (if known)

MM slash DD slash YYYY

Special Identification (tattoo, microchip, etc.)

Sex

Pet Medical History

Previous Veterinary Practice (if any)

Previous Veterinarian (if any)

Last date of vaccines (if known)

Date of last vaccine (if known)

MM slash DD slash YYYY

Is your pet on any medication or supplement?

Yes

If yes, please list the medication or supplement

What food does your pet eat?

Does your pet have allergies or drug reactions?

Yes

If yes, please list the allergies and reactions

Are there any current or past medical conditions of which we should be aware?

Yes

If yes, please comment on the conditions(s) and indicate if they are current or past conditions

Please use the following box to provide us with any other relevant information about your pet

Pet Information - #2

Pet's Name*

Species*

If other species not listed above

Breed (If known)

Color

Date of Birth (if known)

MM slash DD slash YYYY

Special Identification (tattoo, microchip, etc.)

Sex

Pet Medical History

Previous Veterinary Practice (if any)

Previous Veterinarian (if any)

Last date of vaccines (if known)

Date of last vaccine (if known)

MM slash DD slash YYYY

Is your pet on any medication or supplement?

Yes

If yes, please list the medication or supplement

What food does your pet eat?

Does your pet have allergies or drug reactions?

Yes

If yes, please list the allergies and reactions

Are there any current or past medical conditions of which we should be aware?

Yes

If yes, please comment on the conditions(s) and indicate if they are current or past conditions

Please use the following box to provide us with any other relevant information about your pet

Pet Information - #3

Pet's Name*

Species*

If other species not listed above

Breed (If known)

Color

Date of Birth (if known)

MM slash DD slash YYYY

Special Identification (tattoo, microchip, etc.)

Sex

Pet Medical History

Previous Veterinary Practice (if any)

Previous Veterinarian (if any)

Last date of vaccines (if known)

Date of last vaccine (if known)

MM slash DD slash YYYY

Is your pet on any medication or supplement?

Yes

If yes, please list the medication or supplement

What food does your pet eat?

Does your pet have allergies or drug reactions?

Yes

If yes, please list the allergies and reactions

Are there any current or past medical conditions of which we should be aware?

Yes

If yes, please comment on the conditions(s) and indicate if they are current or past conditions

Please use the following box to provide us with any other relevant information about your pet

Pet Information - #4

Pet's Name*

Species*

Breed (If known)

If other species not listed above

Color

Date of Birth (if known)

MM slash DD slash YYYY

Special Identification (tattoo, microchip, etc.)

Sex

Pet Medical History

Previous Veterinary Practice (if any)

Previous Veterinarian (if any)

Last date of vaccines (if known)

Date of last vaccine (if known)

MM slash DD slash YYYY

Is your pet on any medication or supplement?

Yes

If yes, please list the medication or supplement

What food does your pet eat?

Does your pet have allergies or drug reactions?

Yes

If yes, please list the allergies and reactions

Are there any current or past medical conditions of which we should be aware?

Yes

If yes, please comment on the conditions(s) and indicate if they are current or past conditions

Please use the following box to provide us with any other relevant information about your pet

Treatment Authorization & Financial Agreement

I hereby authorize the veterinarians at All Paws & Claws Veterinary Clinic to examine, prescribe for, and treat my animal(s). I understand that any problem that develops with my pet(s) will be treated as deemed best by the veterinarian, the staff, or a representative. I agree that the veterinarian shall perform the exams, treatments, anesthesia, and/or surgical procedures as discussed and agreed upon during the examination and treatment. I assume responsibility for all charges incurred in the care of my animal(s). I also understand PAYMENT IN FULL IS DUE AT THE TIME OF SERVICE. I have read and understood this policy, and I accept responsibility for all fees. I understand that if I fail to pay as agreed, legal action will be taken against me. I also understand that there is a $35 fee on all returned checks.

Consent*

I agree

Owner's Information

Co-Owner's Information

Referral Information

Pet Information - #1

Pet Medical History

Pet Information - #2

Pet Medical History

Pet Information - #3

Pet Medical History

Pet Information - #4

Pet Medical History

Treatment Authorization & Financial Agreement

Contact Us

Clinic Hours

New Client Registration Form

Owner's Information

Co-Owner's Information

Referral Information

Pet Information - #1

Pet Medical History

Pet Information - #2

Pet Medical History

Pet Information - #3

Pet Medical History

Pet Information - #4

Pet Medical History

Treatment Authorization & Financial Agreement

Contact Us

Clinic Hours

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