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CROSSROADS VETERINARY HOSPITAL REGISTRATION TODAY’S DATE: PATIENT’S INFORMATION (FELINE) Name Breed Birthday: Color SEX: MALE / FEMALE SPAYED / NEUTERED Microchip # OWNER’S INFORMATION Owner’s Name Cell #: Spouse/Other Cell #: Address City Home # Work # E-mail @ Zip Employer Do you have any other pets? VACCINE/TEST HISTORY-OFFICE USE ONLY FVRCP Vaccine Rabies Vaccine Purevax/Rabies Tag # Leukemia Vaccine FECAL test date DIRECT FLOAT FIV/LEUK Combo Test FIV LEUKEMIA AUTHORIZATION I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I understand that these charges must be paid at the time of release and that a deposit may be required for surgical treatment. Signature of Owner/Agent Date We accept: Cash, Check, MasterCard, Visa, and Discover