New Patient Registration
CLIENT (HUMAN) INFORMATION
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First Name
Last Name
Address
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Street Address
Apt Number
City
State / Province
Postal / Zip Code
Email Address
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Cell Phone
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Home Phone
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Work Phone
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Preferred method(s) of contact:
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Cell phone
Work Phone
Home Phone
Email
Mail
Current Employer
Secondary Contact
First Name
Last Name
Relationship
Cell Phone
Work Phone
How did you hear about us?
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AUTHORIZATION & RELEASE FOR MEDICAL and/or SURGICAL CARE I, the undersigned as owner and/or agent of the animal(s), do attest that I am at least 18 years old and do hereby authorize the veterinarians of Family Animal Medicine, PLLC and such persons as they designate as their aids and assistants to administer to the patient such diagnostic, therapeutic, anesthetic and/or surgical procedure as they deem necessary for the care of said animal. I hereby certify that I have read and fully understand the above authorization. I also certify that no guarantee or assurance has been made as to results that may be obtained and I completely release any staff veterinarian their aids, assistants, and Family Animal Medicine, PLLC from any and all liability due to death, loss, or any decline in condition of my animal while under their care. I also understand and agree to the terms of payment: all fees are due and payable at the time services are rendered.
SIGNATURE
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Pet 1 Name
*
Species
*
Breed
*
Color
*
Sex of pet
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Female
Male
Spayed/Neutered?
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Yes
No
Unknown
Date of Birth or Age (estimate if needed)
*
Microchipped?
*
Yes
No
Unknown
How long have you owned this pet?
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Origin of Pet
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Stray
Rescue Organization
Breeder
Other
Indoor/Outdoor?
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Indoor
Outdoor
Both
Brand of Pet food
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Medical Conditions:
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Current Medications
*
Drug/Food Allergies
*
Previous Veterinarian
*
May we call to get records and vaccination history?
*
Yes
No
May we share photos of your pet on our social media account and website?
*
Yes
No
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Pet 2 Name
Species
Breed
Color
Sex of pet
Female
Male
Unknown
Date of Birth or Age (estimate if needed)
Spayed/Neutered?
Yes
No
Unknown
Microchipped?
Yes
No
Unknown
How long have you owned this pet?
Origin of Pet
Stray
Rescue Organization
Breeder
Other
Indoor/Outdoor?
Indoor
Outdoor
Both
Brand of Pet food
Medical Conditions:
Current Medications
Drug/Food Allergies
Previous Veterinarian
May we call to get records and vaccination history?
Yes
No
May we share photos of your pet on our social media account and website?
Yes
No
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Add another pet -->
Pet 3 Name
Species
Breed
Color
Sex of pet
Female
Male
Spayed/Neutered?
Yes
No
Date of Birth or Age
Microchipped?
Yes
No
How long have you owned this pet?
Origin of Pet
Stray
Rescue Organization
Breeder
Other
Indoor/Outdoor?
Indoor
Outdoor
Both
Brand of Pet food
Medical Conditions:
Current Medications
Drug/Food Allergies
Previous Veterinarian
May we call to get records and vaccination history?
Yes
No
May we share photos of your pet on our social media account and website?
Yes
No
Back
Finished? Click here!
Add another pet -->
Pet 4 Name
Species
Breed
Color
Sex of Pet
Female
Male
Spayed/Neutered?
Yes
No
Date of Birth or Age
Microchipped?
Yes
No
How long have you owned this pet?
Origin of Pet
Stray
Rescue Organization
Breeder
Other
Indoor/Outdoor?
Indoor
Outdoor
Both
Brand of Pet food
Medical Conditions:
Current Medications
Drug/Food Allergies
Previous Veterinarian
May we call to get records and vaccination history?
Yes
No
May we share photos of your pet on our social media account and website?
Yes
No
Back
Finished? Click here!
Add another pet -->
Pet 5 Name
Species
Breed
Color
Sex of Pet
Female
Male
Spayed/Neutered?
Yes
No
Date of Birth or Age
Microchipped?
Yes
No
How long have you owned this pet?
Origin of Pet
Stray
Rescue Organization
Breeder
Other
Indoor/Outdoor?
Indoor
Outdoor
Both
Brand of Pet food
Medical Conditions:
Current Medications
Drug/Food Allergies
Previous Veterinarian
May we call to get records and vaccination history?
Yes
No
May we share photos of your pet on our social media account and website?
Yes
No
Back
Finished? Click here!
Add another pet -->
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