Sandy Paws Veterinary Clinic New Patient / Pet Registration Form

Sandy Paws Veterinary Clinic New Patient / Pet Registration Form
Name*

First NameLast Name
Pet´s Name:*
Pet´s Species*

DogCatOther
Breed:*
Color:*
Pet´s D.O.B. (or Age)*
Sex:*

MaleFemale
Spayed and Neutered:

YesNo
Are you the owner / Legal guardian of this pet?
Please provide name of any other Owner or Legal Guardian of this Pet:
If not the Owner, how are you related?
Are you over the age of 18?
**Please note we cannot treat a pet without owner’s
written consent. If you are not the owner, we cannot treat the animal without owner’s permission.
Client’s Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prefered Contact Phone:*

Area CodePhone Number
Email
example@example.com
Please list the names of other persons (if any) that you authorize us to release your pet to, for pickup, following treatment:
(Please note that we will not release your pet to family members/neighbors,etc. without their names appearing below or by
written consent from the pet’s owner)
1.
2.
3.
Are there other animals in your household?

YesNo
If yes, what types of animals and how many?
Do you give consent to use photos of your pet on social media and make them a star?

YesNo
How did you hear about us?
If someone referred you to us, please list their name here:
NOTE: We have trained staff to restrain your pet for examination or treatment. If you elect to restrain your own pet, please
understand we cannot be responsible for any injury incurred to you or your pet.
Initial confirming the above information has been read and understood *
THIS SECTION TO BE COMPLETED BY NEW CLIENTS
Reason for today’s visit?:
Please check all symptoms or problems you’ve recently noticed with your pet:

Appetite LossGaggingSneezingBehavioral ChangeGums BleedingIncreased ThirstScratchingIncreased CoughingBreathing ProblemsLimpingLoss of BalanceVomitingDepressionScootingWeaknessDiarrheaUrination/PeeingEye ProblemsShaking HeadBiting Self
NEW PATIENT HISTORY
Has your pet ever bitten someone?
Attacked other animal?
Lunged at/attacked people?
VACCINATION/WELLNESS HISTORY (If known, please check all vaccinations/tests that your pet has
received within the past 12 months):
Dog:

RabiesDistemper (DHLPP)Bordetella (Kennel Cough)Heartworm Test
Cat:

RabiesDistemper (FVRCP)Feline Leukemia/FIVFeline Leukemia Vaccine (FELV)
Is your pet on heartworm prevention?
Is your pet on flea prevention?
What is your pet’s medical history (such as surgeries, ongoing medical issues, allergies, seizures, etc.):
Names of other veterinarians who have treated your pet?
NOTE THAT PAYMENT IS DUE AT TIME SERVICES ARE RENDERED. NO BILLING OR INVOICES.
We accept the following forms of payment: Cash | Credit | Card | Scratch Pay

Note: To help prevent and deter identity theft, we will require a current driver’s license or United States passport - to verify personal information and funds, if applicable. Thank You!

I understand that FULL PAYMENT OF ALL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED TO MY PET and I shall take full responsibility for payment of all charges related to the care of my pet prior to leaving the clinic or when services have been completed. I acknowledge and accept that, should payments not be honored by my bank, credit card organization or by pet insurance organization to Sandy Paws Veterinary Clinic – for any reason – then I shall pay the full amount within five (5) days of demand – including all applicable costs incurred by Sandy Paws Veterinary Clinic (and its agents) for collection of those funds.

As indicated by my signature, I have read and acknowledged all information provided to me on this Registration Form (on these two pages) and verify the information I have provided is correct.
Please confirm you read and understood all the above by typing your full name blow. *
Date

MonthDayYear
Date
Please verify that you are human*
Should be Empty: