Client / Patient Registration Form

CLIENT NAME:

SPOUSE / OTHER:

MAILING ADDRESS:

CITY:

STATE:

ZIP:

COUNTY:

PHYSICAL ADDRESS (if different):

CITY:

STATE:

ZIP:

COUNTY:

HOME PHONE:

() -

WORK PHONE:

() -

MOBILE:

() -

E MAIL ADDRESS:

DRIVERS LICENSE:

EMERGENCY CONTACT NAME:

EMERGENCY CONTACT NUMBER:

PATIENT INFORMATION

NAME:

SPECIES:

	Dog
	Cat

SEX:

	Male
	Female

NEUTERED / SPAYED:

	Neutered
	Spayed

BREED:

COLOR:

BIRTH DATE:

MEDICATIONS:

Name:

SPECIES:

	Dog
	Cat

SEX:

	Male
	Female

NEUTERED / SPAYED:

	Neutered
	Spayed

BREED:

COLOR:

BIRTHDATE:

MEDICATIONS:

HEARTWORM PREVENTION:

	Iverhart Max
	Heartgard
	Sentinel
	Revolution
	Other

FLEA / TICK PREVENTION:

	ProMeris
	Frontline
	Comfortis
	Advantage
	Other

PREVIOUS VETERINARY HOSPITAL:

TELEPHONE:

() -

RELEASE OF MEDICAL RECORDS:

	Yes
	No

I authorize Companion Animal Hospital of Waller to release my pet's medical records as requested to other veterinarians and/or boarding and grooming facilities.

AUTHORIZATION: I assume responsibility for all charges incurred in the care of this animal. I understand that full payment for charges is due at the time of release and that a deposit may be required for surgical or medical treatment. If there is a credit card number on file, I give authorization to charge my card. If my pet is brought into the clinic on an emergency basis, I authorize all care to preserve the life of my pet and to minimize suffering. Further, I understand Companion Animal Hospital of Waller will from time to time photograph or videotape work in progress at our facilities for educational, training, promotional and/or other purposes. This serves as notification that your pet may appear in such photos and/or videotapes, that Companion Animal Hospital of Waller has permission to use them, and there will be no compensation for such usage.

RESPONSIBLE PARTY'S NAME:

DATE:

HOW DID YOU HEAR ABOUT US:

	Friend
	Phone Directory
	Welcome Neighbor
	Advertising
	Drive-by
	Waller Equine Hospital Client
	Dr. Beckham
	OTHER