Pet Registration Form printable pdf download

Pet Registration Form

PET REGISTRATION FORM

Pet’s Full Name (include last name): __________________________________________

DOB: _______ If DOB unknown, estimated age:________________________________

Species: ( )Canine

( )Feline

( )Avian

( )Reptile

( )Other (Please list, e.g.: Ferret, Rabbit,

Guinea Pig, Hamster, Rat, Mouse, Chinchilla, Pig, Fish, etc..):___________________________________

Breed:______________________

Color:_________________________________________________

(

) Male Neutered?________

(

) Female Spayed?_________

Current medications (dose): ____________________________________________________________

Current supplements (dose):_____________________________________________________________

Current medical conditions: _____________________________________________________________

Past medical conditions:________________________________________________________________

Primary Reason for visit? ________________________________________________________________

Does your pet have allergies?________ If yes, please list:______________________________________

Do you or anyone in your family have any life threatening allergies (e.g.: nuts, antibiotics, eggs,

etc…)?___________

If yes, please list allergies:________________________________________________________________

I do hereby authorize the veterinarian to examine, prescribe for and treat the above pet. I assume

responsibility for all charges incurred in the care of the animal.

Signature:_________________________________________________ Date:______________________

(Must be 18 years of age or older)

Print Name:__________________________________________________

Pet Registration Form