Companion Animal Hospital New Client Registration Form

Companion Animal Hospital New Client Registration Form
Thank you for giving us the opportunity to care for your pet. We'll be happy to answer any questions you have about your pet's health. To insure the best care possible, please take the time to fill in this form completely.
Thank you!
Owner Full Name:

First Name Last Name
Spouse Full Name:

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone:

Area Code Phone Number
Cell Phone #1:

Area Code Phone Number
Cell Phone #2:

Area Code Phone Number
Work Phone:

Area Code Phone Number
Email
example@example.com
Emergency Contact:
Name

First Name Last Name
Phone Number

Area Code Phone Number
How did you learn of our clinic?

Facebook/Internet Recommendation Drive by
If recommended, please type their full name
Pet Information
Pet Name
DOG or CAT?
Breed
Color
Date of Birth
Sex
Spayed and Neutered

Yes No
I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pets. I assume responsibility for all charges incurred in the care of these animals. I also understand these charges will be paid at the time of patient release and that a deposit may be required for surgical treatment.
Signature

Clear
Date

Month Day Year
Date
Medical Release

I, give Companion Animal Hospital permission to release my pet(s) medical/vaccine records at any time a request is made. Furthermore, I realize I must request in writing when I no longer wish this to be in effect.
Signature

Clear
Date

Month Day Year
Date
From the Licensing Board
Just a reminder that Rule 1730-01-13 (6) specifically states that client records can only be released with the written permission of the client. The Board has stated that this includes requests of vaccination records from other veterinarians, groomers, and boarding facilities. For more information about this Rule, please see the Board's Policy Statement regarding Release of Patient Records at Board of
Veterinary Medical Examiners-TN.gov
Facebook Release
We love to share our patient photos with the public via our website,Facebook, etc. Do you give permission for us to use your pet’s photos?

YES, My pet was born to be a star!! NO, My animal is shy.
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