New Client Registration





Client Information

Your First Name:
Your Last Name:
Address:
City, State, ZIP:
County:
Home Phone:
Work Phone:
Cell:
Fax:
Your Email:
Work Email:
Employer:
Reminder:

 

Patient Information

Pet #1

Name:
Breed:
DOB:
Color:
Sex: spayed or neutered:
Previous heartworm test/prevention?
Previous FeLV/FIV test?

Pet #2

Name:
Breed:
DOB:
Color:
Sex: spayed or neutered:
Previous heartworm test/prevention?
Previous FeLV/FIV test?

Pet #3

Name:
Breed:
DOB:
Color:
Sex: spayed or neutered:
Previous heartworm test/prevention?
Previous FeLV/FIV test?

Pet #4

Name:
Breed:
DOB:
Color:
Sex: spayed or neutered:
Previous heartworm test/prevention?
Previous FeLV/FIV test?

 

Vaccine History

Canine:

Rabies
DA2PP
Bordetella
Lepto

Feline:

Rabies
FVRCP
FeLV

 

Previous Illness:
When?
Visit Reason:

 

Account Information

Responsible Party for Account:
Address if other than above:
Referred By:
If personal recommendation
If other:

 

I have reviewed the information on this form and it is accurate to the best of my knowledge. I agree to be the financially responsible party and understand that all fees are due at the time services are rendered. I understand that if my account becomes delinquent, my information may be released to a third party collection agency and I will be responsible for all additional costs. All images taken at Raintree Pet Resort + Medical Center are the property of the afore mentioned entity and may be used for promotional purposes. I consent to the use of periodic appointment reminders, phone calls, voice mails, emails, postcards or letters. I have read and accepted all of the above.

Check to confirm submission.

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