Client Registration Form

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First Name
Middle Initial
Last Name
Doctor
or Tech’s
First Name
Middle Initial
Spouse Last Name
Initials
__________
Address
Apt./Lot#
Email:
City
State
Zip Code
Client
Acct. #
Home Phone # (_____)
Cell Phone # (
)
__________
Work Phone # (
)
Cell Phone # (
)
(If paying by check, check writer’s information below is REQUIRED on check & below.)
Name on Driver’s License
License ST
#
Exp. Date____
DOB
Race
Sex
Hair color
Eye color
Height
Weight _____
Please initial yes or no for each:
Have any of your pets ever had a reaction to vaccinations? Yes___ No_____
Are they currently sick or pregnant? Yes__ No__
Have they bitten anyone in the last 10 days? Yes____ No______
***********************************************************************************
Pet’s Name
#
Breed
Color
Dog
Cat
(Male
Neutered?
) (Female
Spayed? ) Microchip Wanted?
Rabies Tag #
Date of Birth
/
/
Heartworm Test Wanted?
Weight
Issued Today_______
************************************************************************************
Pet’s Name
#
Breed
Color
Dog
Cat
(Male
Neutered?
) (Female
Spayed? ) Microchip Wanted?
Rabies Tag #
Date of Birth
/
/
Heartworm Test Wanted?
Weight
Issued Today_______
************************************************************************************
Pet’s Name
#
Breed
Color
Dog
Cat
(Male
Neutered?
) (Female
Spayed? ) Microchip Wanted?
Rabies Tag #
Date of Birth
/
/
Heartworm Test Wanted?
Weight
Issued Today_______
************************************************************************************
Dogs
Cats
Package A:…...........................……...........$10
Package A:….................................................$10
Method of
Rabies
Rabies
Payment:
…...…...........$28
Package B:
$29
Package B:
Minimum Protection….…............
For Inside Only Cats
Cash________
Rabies – DHPP
Rabies – FVRCPC
Package C:
........................$43
Package C:
..........................$47
Better Protection
For Outside Cats
Check_______
Rabies – DHPP – Intranasal Bordetella
Rabies – FVRCPC – Leukemia
Check #_____
Package D:
$69
Maximum Protection.....…...........
Rabies-DHPP-Intranasal Bordetella-K-9 Influenza
Amount Paid:
Also available: Lyme Disease Vaccine $28 & Rattlesnake Vaccine $27
____________
Vaccinations will NOT be provided to pets with a history of previous reactions to vaccinations.
For dogs over 6 months of age, a negative heartworm test must have been performed by our clinic before we can dispense heartworm medication.
Heartworm Test only $8 w/negative results & purchase of a year’s worth of heartworm preventative at time of testing.
We accept cash and checks only We offer puppy & kitten shots! Microchipping Available
PRICES ARE SUBJECT TO CHANGE

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