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SPAH Client Registration Form

Client Registration Form
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Are you a senior citizen?
IN THE CASE OF EMERGENCY and no one is reachable at the above numbers, please contact:
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How did you hear about us?
Referred By (Check One):
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Photo Authorization: We sometimes take photos of pets while at the hospital. These photos may be used on our website or Facebook page. When published we may identify them by your pet's name only.
Pet Registration Form
Species
Spayed or Neutered?
Is this pet new to your home?
For New Pet Owners:
This pet was obtained from a
Is this a stray animal?
Other Pets:
Do you have any other pets?
How Many:
Please enter the date of your pet's last vaccination and test:
Is this dog on heartworm preventative?
Please enter the date of your pet's last vaccination and test:
Is your cat allowed to go outdoors?
Please enter a date of your pet's last vaccination and test:
Medical History For Your Pet Listed Above:
Any adverse reactions to prior medications/vaccinations/treatments?
Form of Payment
Authorization of Services: I, the undersigned owner, authorized agent of the owner, or Good Samaritan responsible for seeking veterinary care for the pet identified above, certify that I am over eighteen years of age, and hereby consent to the examination of this pet by staff veterinarians at this veterinary practice. I understand that an estimate of the costs for veterinary services is available and that I am encouraged to discuss all fees attendant to such care before services are rendered. I understand that payment is expected at time services are rendered and I assume all financial responsibility for all said services.
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Signature of