New Client Registration Form |
| If an appointment is scheduled, what is the scheduled date and time? |
| Scheduled Date : |
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Scheduled Time : |
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| Pet Owner's Name : |
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| Address : |
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City : |
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| State : |
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Zip : |
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| Home Phone : |
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Work Phone : |
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| Spouse or Co-Owner |
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Work Phone : |
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| Emergency Contact : |
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Home Phone : |
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| Drivers License # : |
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Social Security # : |
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| Email Address : |
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| How did you hear about The Animal Hospital of Dunedin? |
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| Referred by (We would like to thank them) : |
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| Are there other pets in your household? |
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| If yes, please indicate quantity below : |
Dogs
Cats
Birds
Reptiles
Ferrets
Other (Please specify)
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Pet Information #1 |
| Pet's Name : |
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Birth Date : |
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| Species : |
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Breed : |
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| Color : |
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| Female Spayed : |
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| Male Neutered : |
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Medical Conditions (allergies, drug reactions, heart conditions, etc.) |
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Vaccination History (indicate the date (month/year) your pet received the following vaccinations) |
| Canine Distemper / Parvo : |
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| Bordetella : |
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Rabies : |
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| Lepto : |
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Other : |
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| Feline Distemper : |
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Rabies : |
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| Feline Leukemia : |
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FIP : |
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Nutrition |
| Dry Brand : |
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| Canned Brand : |
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| Table Scraps? |
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Dental Care |
| Do you brush your pet's teeth? |
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| Date of last dental cleaning? |
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Heartworm Preventative |
| Is your pet currently taking heartworm preventative? |
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If yes,
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Brand : |
Microchip Identification # : |
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Medical Records |
| Name of hospital where they can be obtained : |
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Pet Information #2 |
| Pet's Name : |
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Birth Date : |
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| Species : |
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Breed : |
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| Color : |
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| Female Spayed : |
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| Male Neutered : |
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Medical Conditions (allergies, drug reactions, heart conditions, etc.) |
|
Vaccination History (indicate the date (month/year) your pet received the following vaccinations) |
| Canine Distemper / Parvo : |
|
| Bordetella : |
|
Rabies : |
|
| Lepto : |
|
Other : |
|
| Feline Distemper : |
|
Rabies : |
|
| Feline Leukemia : |
|
FIP : |
|
Nutrition |
| Dry Brand : |
|
| Canned Brand : |
|
| Table Scraps? |
|
Dental Care |
| Do you brush your pet's teeth? |
|
| Date of last dental cleaning? |
|
Heartworm Preventative |
| Is your pet currently taking heartworm preventative? |
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If yes,
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Brand : |
Microchip Identification # : |
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Medical Records |
| Name of hospital where they can be obtained : |
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Pet Information #3 |
| Pet's Name : |
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Birth Date : |
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| Species : |
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Breed : |
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| Color : |
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| Female Spayed : |
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| Male Neutered : |
|
Medical Conditions (allergies, drug reactions, heart conditions, etc.) |
|
Vaccination History (indicate the date (month/year) your pet received the following vaccinations) |
| Canine Distemper / Parvo : |
|
| Bordetella : |
|
Rabies : |
|
| Lepto : |
|
Other : |
|
| Feline Distemper : |
|
Rabies : |
|
| Feline Leukemia : |
|
FIP : |
|
Nutrition |
| Dry Brand : |
|
| Canned Brand : |
|
| Table Scraps? |
|
Dental Care |
| Do you brush your pet's teeth? |
|
| Date of last dental cleaning? |
|
Heartworm Preventative |
| Is your pet currently taking heartworm preventative? |
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|
If yes,
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Brand : |
Microchip Identification # : |
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Medical Records |
| Name of hospital where they can be obtained : |
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I ASSUME RESPONSIBILITY FOR ALL CHARGES INCURRED IN THE CARE OF MY PET. I ALSO UNDERSTAND THAT THESE CHARGES MUST BE PAID AT THE TIME SERVICES ARE RENDERED AND THAT A DEPOSIT MAY BE REQUIRED FOR HOSPITALIZATION AND SURGICAL PROCEDURES. I UNDERSTAND THAT THE ANIMAL HOSPITAL OF DUNEDIN DOES NOT BILL. ACCEPTABLE METHODS OF PAYMENT ARE CASH, CHECK, VISA, MASTERCARD, AMERICAN EXPRESS, DISCOVER AND CARE CREDIT. I ALSO UNDERSTAND THAT IF MY ACCOUNT IS NOT PAID IN FULL THAT I WILL BE LIABLE FOR A MONTHLY FINANCE CHARGE OF 1.5% AND ANY FEES THAT MIGHT BE INCURRED FOR THE SERIVCES OF AN OUTSIDE COLLECTION AGENCY. |
Signature : (Type Full Name) |
| Date : |
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