Client Registration Form
Name:____________________________________________________________
Address:
(Street)____________________________________________________
City,
State, Zip Code:
________________________________________________
Driver’s
License or I. D. Card Number: _______________ Expiration
date:_________
Social
Security Number: ____________________ Birthday:
___________________
Occupation:
________________________________
Employer:
_______________________________________
Address:
(Street & Number)
__________________________________________
City,
State, Zip Code:
________________________________________________
Telephone
Numbers (please include area code):
e-mail:
______________________________________________________
Home:(____)_____-______________
Work:(____)_____-_____________
Cell:(____)_____-______________
Pager:(____)_____-_____________
Referred
By: ______________________________________
SBC
Yellow Pages _______ Greater Waco Yellow Pages (Black Book)
_________
Baylor
Directory ______ Saw Sign _______ Friend ________
Other __________
Name
of friend:
________________________________________________________
Alternate
Contact:
______________________________________________________
Please
circle: Spouse
Partner Co-owner Other:
___________________________
Address:
(Street & number if different than above)
_____________________________
City,
State, Zip Code:
____________________________________________________
Telephone
Numbers: (please include area code)
Home:(____)_____-_______________
Work:(____)_____-______________
Cell:(____)_____-________________ Pager:(____)_____-_______________
PROFESSIONAL
FEES ARE TO BE PAID AT THE TIME SERVICES ARE PERFORMED
How will you be making payment
today? * Sorry, we DO NOT
charge!
Cash
____ Check ____ Visa ____ M/C ____ Discover ____ American Ex.
____
* In
admitting my pet(s) for diagnostics, treatment, or surgery, I
authorize the veterinarians of Emerson Animal Hospital, and their
support staff, to administer such treatment and/or perform such
diagnostic or surgical procedures as deemed necessary.
* No
guarantee or assurance can be made as to the results that may be
obtained.
*
Further, I understand that a deposit of 50% is required before
services are performed and I assume full financial responsibility
for all charges incurred by my pet. I realize that these
charges may exceed a given estimate if complications arise. I
understand that I will be contacted prior to treatment, if
possible, should complications occur.
* I
understand that I am personally financially responsible
for all services rendered by the doctors and staff of Emerson
Animal Hospital and that payment is due on the date
performed.
Signature:
_________________________
Signature:_________________________
*
Issuers of bad checks and persons attempting theft of services will
be prosecuted to the full extent of the law
Patient Registration
Please
circle:
|
Dog
|
Cat
|
Bird
|
Rabbit
|
Reptile
|
Rodent
|
Other_______
|
Pet’s
Name: _____________________________ Breed:
_______________________
Birthdate/Age (approx. if unknown):
_______________________
Please
circle: Male
Neutered
Female
Spayed
Color/Markings: ___________________ Identification:
__________________
Vaccination
history (please circle those that apply and provide the date
of the last vaccination):
Dogs: Rabies
Distemper-Parvo Bordetella/Kennel
Cough Lyme
Date:________
____________ _____________
________
Cats:
Rabies Feline upper
respiratory Feline
Leukemia FIP
Date: _________
_____________
____________ ________
Ferrets:
Rabies
Distemper
Date:
____________
______________
Where:
_____________________________________________________________
What
are you feeding your pet?:
_________________________________________
Do you
have, or have you ever had, other pets treated by us before?:
____________
If
yes, what were their names? :
_________________________________________
