Timberland Animal Clinic Registration Form
(Print and bring in with you)
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)_________________________________________________________