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Laurelwood Veterinary Clinic


Welcome to Laurelwood Veterinary Clinic!



Registration Form

Microchip # ____________________

 

Owner: ______________________________________________Date:_____________

Spouse/Partner: ______________________________ Cell Phone: __________________

Address: _______________________________City: ______________ Zip: ________

Home Phone: ____________________ Work Phone: __________________

Email address: ___________________________________

Emergency contact information: _________________________ Phone: _____________

How did you hear about us? : ___ yellow pages   ____ sign ____ recommendation

Recommendation, if so who? ________________________________________

Are you a new client? _____ Existing client? _____ or previous client? __________

Number of pets? ________ Dogs ____ Cats _____ Other______

Reason for visit: _________________________________________________________

 


Pet Health History
 

Name of pet: ________________ Dog _______ Cat _______ other _________

Breed: _________________ Color: _____________ Birth date: ____________

Male: ____ Neutered: _____            Female: ____ Spayed: ______

 

Vaccine History (Date and type of vaccine): __________________________________

______________________________________________________________________

Please check any symptoms or problems that you have noticed about your pet:

___ Behavior problems     ___ Coughing    ___ Diarrhea    ___ Eye bulging or blood shot

___ Bleeding gums           ___ Gagging      ___ Lack of appetite     ___ Limping

___ Scooting                     ___ Vomiting    ___ Shaking head    ___ seems depressed

___ Breathing problems   ___ Loss of balance     ___ Weakness

___ increased thirst and/ or urination

___ other (please explain): _____________________________________________

 

Pet’s current medication: _________________________________________________

_____________________________________________________________________

Pet’s current diet: _______________________________________________________

 

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 also understand that these charges will be paid at the time of release and that a deposit maybe required for surgical treatment.

 

Signature of owner: ___________________________________ Date: _______________

Method of payment: check_____ Cash ____ MasterCard ___ Visa ____ other ______

 

For Office Use:

DB ________   WC ________    SC ________   IA  ________   RP  ________Type your paragraph here.