New Client Registration Form - Baker Veterinary Clinic printable pdf download

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BAKER VETERINARY CLINIC

NEW CLIENT REGISTRATION FORM

Date :

name of the owner or legal representative: _______________________

___ / ___ / 20___

Address: _____________________________________________# apartment: ________

City:______________________ State ____ Zip: ________

Phone Home: ____________ Phone Work:_____________ Phone Cell: ____________Text Y/N

Fax: __________________Email: ______________________________________________

Name of the Co - owner: ______________________ phone: _______________________

Pet Insurance Company:___________________________________________

How did you hear of us? Check one of the following:

TV_____ Internet_____ Yellow pages______

Referred by a friend____ Who can we thank? ________________________other: ______________________

Please give us the name and phone number of your previous vet:

___________________________________________________________________________

Please complete the following information for your pet (s):

The pet's name

Sex

Spayed/

Date of birth

Vaccines last

Breed

Color

(M/F)

Neutered

date

I authorize Baker Veterinary Clinic to administer any medication, test, anesthetic or surgical procedure

which the veterinarian considers necessary to maintain the health, safety and welfare of my pet (s).

I understand that as a prerequisite to my pet (s) being admitted, vaccines must be current and that my pet (s)

must is free from external and internal parasites (fleas, ticks, worms, etc.). This will be corrected at the time of

admission and charged accordingly. All fees for professional services must be paid at the time of discharge.

I now assume legal responsibility for all services rendered. In the event that came to be necessary to collect

fees from the services of a lawyer or a collection agency, I am aware that I will be responsible for all attorneys fees,

collection agency, file charges financial, interest and any other costs, depositions, and other reasonable attorney fees

incurred. It is agreed that the place of all the actions will be in Palm Beach County, Florida.

In the event that my pet is abandoned at Baker Veterinary Clinic, hereby I authorize Dr. Baker or the staff

to humanely dispose of such pet if it is not collected within seven calendar days after being notified by mail

certified or registered to the address that the clinic shows to be the most recent.

NOTE: Photos or videos may be taken and used at Baker Veterinary Clinic’s discretion on Baker

Veterinary Clinic’s Website, Facebook, Printed Media, or other Social Sites Initial_______

Signature of the owner or responsible agent:______________________________ Date:_________

New Client Registration Form - Baker Veterinary Clinic

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