Timberland Animal Clinic  Registration Form

Registration Form

Thank you for giving Timberland Animal Clinic the opportunity to care for your pet. Please fill out the following information to make your visit run more smoothly.
 

____________________________________________________________________
Owner's full name                                                   Co-owner's full name

________________________________________________________________________
Home phone number                          Home address                            City                   Zip

_______________________________             _____________________________________
(Owner's DL#/state)    (Owner's DOB)              ( Co-owners' DL#/state)      (Co-owner's DOB)

___________________________________________________________________________
Owner's employment    Title          work  phone    Co-owner's employment         Title      work phone 

E-mail address(for purposes of sending reminders to you)____________________________

How did you become aware of our clinic?
Yellow pages:Dex______Verizon_______ Clinic Sign______Web_____Location______

Personal Recommendation--Whom may we thank?___________________________________

Other information about yourself:_________________________________________________
 
 _______We require a 24 hour notice for cancellation  of any scheduled appointment. Our ZERO TOLERANCE policy allows us to discontinue veterinary service at our discretion.

Financial  Policy
Timberland Animal Clinic requires payment in full for professional services rendered at time of discharge from the Clinic.  As legal owner or responsible agent of the listed animal(s) I certify  I have read and agree to the above financial policy. I hereby assume financial responsibility for all services rendered.

Please indicate method of payment: Cash______Visa/MC______Debit______
                                                 (We do not accept checks)
Client Signature:____________________________________________date:_____________

                   Our Staff looks forward to meeting you and taking care of your pet family.
 
 
 
 

Pet Health History
Pet  #1

 

Pet Name	Male/female Neutered/spay	Age, D. O . B.
Breed	color/markings	dog, cat, other

Current medications:_____________________________________________________________________

Allergies (food, medications, environmental)____________________________________________________

Previous illnesses or surgeries_______________________________________________________________

Diet(type of foods you feed your pet)_________________________________________________________

Pet #2

 

Pet Name	Male/female Neutered/spay	Age, D. O . B.
Breed	color/markings	dog, cat, other

Current medications:_____________________________________________________________________

Allergies (food, medications, environmental)____________________________________________________

Previous illnesses or surgeries_______________________________________________________________

Diet(type of foods you feed your pet)_________________________________________________________
 
 
 
 

Pet#3

 

Pet's name	Male/female Neutered/spay	Age, D. O . B.
Breed	Color, markings	dog, cat, other

Current medications:_____________________________________________________________________

Allergies (food, medications, environmental)____________________________________________________

Previous illnesses or surgeries_______________________________________________________________

Diet(type of foods you feed your pet)_________________________________________________________