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Pet Information
How many pets would you like to register?
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1
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4
Pet 1 Information
Pet 1: Name
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Pet 1: Age/Date of Birth
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Pet 1: Species
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Dog
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Pet 1: Is it an indoor or an outdoor pet?
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Pet 1: Breed
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Pet 1: Sex
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Male
Male/Neutered
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Female/Spayed
Pet 1: Color/Markings
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Pet 1: Is your pet microchipped?
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Pet 1: Microchip ID:
Pet 1: Does your pet have any known allergies or drug reactions?
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Pet 1: If your pet has any known allergies or drug reactions, then please list them.
Pet 1: Is your pet currently being treated for any medical conditions?
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Pet 1: If your pet is currently being treated for any medical conditions, then please describe them.
Pet 1: Has this pet had any previous medical problems or issues?
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Yes
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Pet 1: If your pet has had any previous medical problems or issues, then please describe them.
Pet 1: We love sharing photos of our wonderful clients! Do we have your consent to share your pet's image on our social media channels and website? We will never use your full name and personal information.
*
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Pet 2 Information
Pet 2 Information
Pet 2: Name
*
Pet 2: Age/Date of Birth
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Pet 2: Species
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Dog
Cat
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Pet 2: Is it an indoor or an outdoor pet?
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Outdoor
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Pet 2: Breed
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Pet 2: Sex
*
Please Select
Male
Male/Neutered
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Female/Spayed
Pet 2: Color/Markings
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Pet 2: Is your pet microchipped?
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Yes
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Not sure
Pet 2: Microchip ID:
Pet 2: Does your pet have any known allergies or drug reactions?
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Yes
No
Pet 2: If your pet has any known allergies or drug reactions, then please list them.
Pet 2: Is your pet currently being treated for any medical conditions?
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Yes
No
Pet 2: If your pet is currently being treated for any medical conditions, then please describe them.
Pet 2: Has this pet had any previous medical problems or issues?
*
Yes
No
Pet 2: If your pet has had any previous medical problems or issues, then please describe them.
Pet 2: We love sharing photos of our wonderful clients! Do we have your consent to share your pet's image on our social media channels and website? We will never use your full name and personal information.
*
Yes
No
Pet 3 Information
Pet 3 Information
Pet 3: Name
*
Pet 3: Age/Date of Birth
*
Pet 3: Species
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Dog
Cat
Other
Pet 3: Is it an indoor or an outdoor pet?
Indoor
Outdoor
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Pet 3: Breed
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Pet 3: Sex
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Please Select
Male
Male/Neutered
Female
Female/Spayed
Pet 3: Color/Markings
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Pet 3: Is your pet microchipped?
*
Yes
No
Not sure
Pet 3: Microchip ID:
Pet 3: Does your pet have any known allergies or drug reactions?
*
Yes
No
Pet 3: If your pet has any known allergies or drug reactions, then please list them.
Pet 3: Is your pet currently being treated for any medical conditions?
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Yes
No
Pet 3: If your pet is currently being treated for any medical conditions, then please describe them.
Pet 3: Has this pet had any previous medical problems or issues?
*
Yes
No
Pet 3: If your pet has had any previous medical problems or issues, then please describe them.
Pet 3: We love sharing photos of our wonderful clients! Do we have your consent to share your pet's image on our social media channels and website? We will never use your full name and personal information.
*
Yes
No
Pet 4 Information
Pet 4 Information
Pet 4: Name
*
Pet 4: Age/Date of Birth
*
Pet 4: Species
*
Dog
Cat
Other
Pet 4: Is it an indoor or an outdoor pet?
Indoor
Outdoor
Both
Pet 4: Breed
*
Pet 4: Sex
*
Please Select
Male
Male/Neutered
Female
Female/Spayed
Pet 4: Color/Markings
*
Pet 4: Is your pet microchipped?
*
Yes
No
Not sure
Pet 4: Microchip ID:
Pet 4: Does your pet have any known allergies or drug reactions?
*
Yes
No
Pet 4: If your pet has any known allergies or drug reactions, then please list them.
Pet 4: Is your pet currently being treated for any medical conditions?
*
Yes
No
Pet 4: If your pet is currently being treated for any medical conditions, then please describe them.
Pet 4: Has this pet had any previous medical problems or issues?
*
Yes
No
Pet 4: If your pet has had any previous medical problems or issues, then please describe them.
Pet 4: We love sharing photos of our wonderful clients! Do we have your consent to share your pet's image on our social media channels and website? We will never use your full name and personal information.
*
Yes
No
Primary Veterinarian
Does your pet currently have a primary veterinarian?
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No
Primary Veterinarian Office Name
Location
Phone Number
Please enter a valid phone number.
Do we have your permission to contact that veterinarian office to transfer your pet's records to our office?
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Records
Please upload your pet records.
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Pet Insurance
Do you have pet insurance?
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No
If you have pet insurance, please list the company name and policy number.
How did you hear about our practice?
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Referral From Another Veterinary Hospital
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Please let us know who referred you (so we can thank them!)
If you selected "other," please briefly explain how you heard about our practice.
Agreement
We will gladly prepare a written estimate if you desire. Feel free to ask for this with any of our staff.
I hereby authorize the veterinarian to examine, prescribe for, or treat the above-described pet(s).
To the best of my knowledge, I affirm the following pet(s):
1. no known or diagnosed allergies to vaccines,
2. The Animalife Veterinary Center uses the finest vaccines available, however, a vaccine reaction is possible, but rare.
3. Should my pet(s) become ill due to vaccine, I will not hold Animalife Veterinary Center or its affiliates responsible.
4. Being aware of these facts, I give my permission to the Animalife Veterinary Center to administer the vaccines recommended.
5. If applicable, I will not give HEARTWORM PREVENTATIVE without NEGATIVE test results.
I assume responsibility for all charges incurred in the care of the animal. I also understand that these charges will be paid at the time services are rendered. Owner agrees to pay all charges incurred as a result of any visit to or care rendered to Owner’s at The Animalife Veterinary Center at the time said services are rendered.
In the event that the said charges are not paid upon rendering services; the owner agrees to pay all costs, fees, and expenses, including the reasonable attorney fees, incurred as a result to collect charges.
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