HOW DID YOU HEAR ABOUT PETHOSPITAL? (Please Check)

WELCOME TO PET HOSPITAL CLIENT REGISTRATION

HOW DID YOU HEAR ABOUT PETHOSPITAL? (Please check)

Advertising: Local Flavor AD_____ Hometown OC Magazine AD _____ Money Mailer AD_____ Other______

Whatin the ADhelped you decide to come to this hospital?______

Online: Google_____ Our Website______Facebook______Twitter______Instagram______Other______

Other Referral Sources: Petsmart___ City______Petco____ City______Wagon Train____ Petopia____ Farmer's Market____ Pet Event______Other______

Pet Rescue______Pet Sitter______Other Vet______

Referred by Location ______: Specifically: Drove by ( ) Near home ( ) Stater Bros ( ) Saw Banner ( ) Other ( )

Personal Referral ______: Who may we thank? Name First/Last______

WOULD YOU LIKE INFORMATION ON PET INSURANCE TODAY? NO ( ) YES ( )

Today's date______

Owner’s Name______Spouse’sName ______

Your Employer______Work Phone______

Spouse’s Employer______Work Phone______

Home Address______

City State Zip

YourCell Ph.#______Spouse's Ph.#______Home Ph. #______

Drivers License#______(For your protection we ask that we have record of your license)

Your D.O.B.(We will need this on file for dispensing any controlled drugs)

E-mail ______@ ______

(Our preferred method for confirming upcoming appointments is via email or text. You can access your pet's personal health portal through our website. Your email is your login. You can also create your personal preference to opt in or out of hospital specials, reminders, and newsletters, etc.)

*Any pet not picked up within the time required by California Civil Code shall be determined abandoned by owner and will be handled according to California Civil Code. I understand this action will not, however, relieve me from paying all charges for services rendered and all legal and/or court costs incurred in connection with collection and said fees.

* Photo Release: I grant Pet Hospital and its representatives and employees the right to take photographs of me and/or my pet and to copyright, use and publish the same in print and/or electronically. I agree that PetHospital may use such photographs of me and or my pet with or without my name and for any lawful purpose, including for example, such purposes as publicity, illustration, advertising, and web content. Please check one below.

( ) The above may take photos of me and/or my pet. ( ) The above may NOT take photos of me and/or my pet.

Please provide your username for Facebook and/or Instagram so we can tag your pet! ______

Payment in full is required at the time services are rendered. We are unable to extend credit.A deposit may be required upon admission of patient into PetHospital. For any outstanding balances there are monthly $2.00 billing and 1.5% interest fees.

We accept Cash, Check, Visa, Mastercard, Discover, TAC, and Care Credit.There is a $200.00 minimum for Care Credit transactions.

I, the undersigned,assume financial responsibility for all charges incurred to patient at PetHospitaland agree to pay all such charges at the time of release of such patient.

______

Signature of Owner or Authorized Agent 18 years or older Receptionist

Additionalinformation to read & sign upon arrival

TELL US ABOUT YOUR PET:NAME______ D.O.B.______

Circle Sex:Male / Neuter OR Female / Spay Circle Species:Canine Feline Bird Reptile Rodent Other

Breed______Color: ______Markings______

Pet’s Diet: Dry ( ) Can( ) Treats:______

Is your pet on any medications? If so, which: ______

Allergies?:______Behavioral problems?:______

Chronic medical conditions?: ______

Pet Microchipped: Y / N #:______AKC Registered: Y/N #:______

Pet Health Insurance: Y/N Company:

VACCINES ARE REQUIRED FOR ALL PETS BEING ADMITTED FOR BOARDING, GROOMING OR TREATMENT. PLEASE ATTACH YOUR PET'S VACCINE RECORDS OR NOTE WHERE THEY WERE DONE ALONG WITH PHONE NUMBER OF CLINIC AND WE WILL CONTACT THEM. ANY PET PAST DUE OR WITH NO HISTORY MUSTBE VACCINATED IN ORDER TO BE ADMITTED.

Name of Facility ______Phone______

REQUIRED VACCINES DOGS: DAPP, RABIES, BORDETELLA

CAT: FVRCP, RABIES, FELV (if under 3yrs old)

______

For Office Use Only :

Verified vaccines: DAPP Date done______Rabies Date done______Bordetella Date done______

FVRCP Date done ______Rabies Date done______FELV Date Done______

Verified by ______

TELL US ABOUT YOUR PET:NAME______ D.O.B.______

Circle Sex:Male / Neuter OR Female / Spay Circle Species:Canine Feline Bird Reptile Rodent Other

Breed______Color: ______Markings______

Pet’s Diet: Dry ( ) Can( ) Treats:______

Is your pet on any medications? If so, which: ______

Allergies?: ______Behavioral problems?:______

Chronic medical conditions?: ______

Pet Microchipped: Y / N #:______AKC Registered: Y/N #:______

Pet Health Insurance: Y/N Company:

VACCINES ARE REQUIRED FOR ALL PETS BEING ADMITTED FOR BOARDING, GROOMING OR TREATMENT. PLEASE ATTACH YOUR PET'S VACCINE RECORDS OR NOTE WHERE THEY WERE DONE ALONG WITH PHONE NUMBER OF CLINIC AND WE WILL CONTACT THEM. ANY PET PAST DUE OR WITH NO HISTORY MUSTBE VACCINATED IN ORDER TO BE ADMITTED.

Name of Facility ______Phone______

REQUIRED VACCINES

DOGS: DAPP, RABIES, BORDETELLA

CAT: FVRCP, RABIES, FELV (if under 3yrs old)

______

For Office Use Only :

Verified vaccines: DAPP Date done______Rabies Date done______Bordetella Date done______

FVRCP Date done ______Rabies Date done______FELV Date Done______

Verified by ______