Client Registration Form -

Client Registration Information

Name*

First Last

Social Security Number*

Address*

Street Address Address Line 2 City State ZIP Code

Your Email

Employer*

Home Phone

Cell Phone

Work Phone

Partner/Co-Owner Information

Name of Partner/Co-Owner

First Last

Social Security Number

Employer

Additional Information

How did you learn about our clinic?

Yellow Pages
Sign
Recommendation
Other

If recommended, by whom?

Method of Payment*

Cash
Check
Major Credit Card
Care Credit (Finance Program)

Number of Pet Owned (Include names and species please)

Reason For Your Visit*

Pet Health History

Name of Pet*

Pet Species*

Dog
Cat

Breed*

Color*

Birth Date or Age*

Sex*

Male, Intact
Male, Neutered
Female, Intact
Female, Neutered

Vaccination History (Date and type of last vaccination)*

Prior Surgeries*

Prior Illnesses*

Pet's Current Medications

Describe Your Pet's Diet*

Consent*

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 treatment.

I hereby authorize Flanary Veterinary Clinic, PLLC to photograph, take motion pictures, take video footage, and/or make electric sound recordings of me and my pet.

I authorize the use of any such photographic or electronic reproductions of me and my pet for any purpose. (I understand that I may be identifiable from such photographic and electronic reproduction). We will gladly give an estimate first.

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Client Registration Form

Client Registration Information

Partner/Co-Owner Information

Additional Information

Pet Health History

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