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WELCOME TO PET HOSPITAL CLIENT REGISTRATION HOW DID YOU HEAR ABOUT PET HOSPITAL? (Please check) Advertising: Local Flavor AD_____ Hometown OC Magazine AD _____ Money Mailer AD_____ Other_________ What in the AD helped you decide to come to this hospital?___________________________________________ Online: Google_____ Our Website______ Facebook______ Twitter_______ Instagram________ Other__________ Personal Referral ______: Who may we thank? Name First/Last___________________________________________ 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 ( ) Today's Date Owner’s Name _________________________________ Spouse’s Name ________________________________ Your Employer _________________________________Work Phone ____________________________________ Spouse’s Employer ______________________________ Work Phone _________________________________ Home Address ____________________________________________________________________________________ City State Home Phone_____________________________________ Zip Cell Phone _________________________________ 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 will also be able to access your pets personal health portal through our website. Your email will be used as your login. You can also create your personal preference to opt in or out of hospital specials, vaccine and service reminders, and newsletters.) *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 Pet Hospital 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. 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 in to Pet Hospital. 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 Pet Hospital and 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 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 MUST BE VACCINATED IN ORDER TO BE ADMITTED. Name of Facility _______________________________________________ Phone_______________________ REQUIRED VACCINES DOGS: DAPP, RABIES, BORDETELLA 6 MO 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 MUST BE VACCINATED IN ORDER TO BE ADMITTED. Name of Facility _______________________________________________ Phone_______________________ REQUIRED VACCINES DOGS: DAPP, RABIES, BORDETELLA 6 MO 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 ________________