Google Registration Form - Timberland Animal Clinic - Timberland Animal Clinic

Registration Form


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Timberland Animal Clinic  Registration Form

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18110 SE Division Portland OR 97236

503.665.1194

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 smoothly.

____________________________________________________________________

Owner’s full name________________________________________________

Home phone_____________________________________

mobile phone_____________________________________

work phone_____________________________________

Co-owner’s full name______________________________________________

mobile phone_____________________________________

work phone_____________________________________

Home address____________________________________________________________________________

City_____________________________________

Zip_____________________________state________

(Owner’s DL#/state) _____________________________

******************************************************

( Co-owners’ DL#/state) ______________________________

Owner’s employment___________________________________________

field title___________________________________________

Co-owner’s employment___________________________________________

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

____________________________

How did you become aware of our clinic?

Yellow pages: Dex______SuperPages_______ Clinic Sign______Web_____Location______

Personal Recommendation–Whom may we thank?(we send a clinic gift certificate)___________________________________

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 when discharged 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_________________(circle one)male/female    neuter/spay    dog___cat_____ other______________

Breed______________________ Color/markings      D.O.B.__________

Last Clinic vaccinations were given and when:___________________________________________________

Current medications:_____________________________________________________________________

Allergies (food, medications, environmental)____________________________________________________

Previous illnesses or surgeries_______________________________________________________________

Diet(type of foods you feed your pet)_________________________________________________________

Pet #2

Pet name_________________(circle one)male/female    neuter/spay    dog___cat_____ other______________

Breed______________________ Color/markings      D.O.B.__________

Last Clinic vaccinations were given and when:___________________________________________________

Current medications:_____________________________________________________________________

Allergies (food, medications, environmental)____________________________________________________

Previous illnesses or surgeries_______________________________________________________________

Diet(type of foods you feed your pet)_________________________________________________________

 

Pet#3

Pet name_________________(circle one)male/female    neuter/spay    dog___cat_____ other______________

Breed______________________ Color/markings      D.O.B.__________

Last Clinic vaccinations were given and when:___________________________________________________

Current medications:_____________________________________________________________________

Allergies (food, medications, environmental)____________________________________________________

Previous illnesses or surgeries_______________________________________________________________

Diet(type of foods you feed your pet)_________________________________________________________