Client Registration form

Please fill out our Client Registration Form prior to your first visit
Please arrive at least 10-15 minutes early for your first appointment

Client Information

Name (Last Name First)

Pronouns

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Home Phone

Work Phone

Cell Phone

Significant Other/Emergency Contact Name

Phone

Email Address

How did you learn about our practice?

Pet Information

Pet’s Name

Spayed / Neutered

Birthdate

Breed

Color/Markings

Describe your pet’s diet

List your pet’s current medications

Pet’s History

(Check all that pet has received)

Distemper/Parvo (Dog)

Bordetella (Kennel Cough-Dog)

CIV (Canine Flu)

Rabies (Dog/Cat)

FVRCP (Infectious Disease-Cat)

Feline Leukemia

Prior Illness

Prior Surgery

Other

Do you have prior records?

Prior Veterinarian’s name & phone #

Financial Policy
Payment in full is due when services are rendered. We accept cash, check, American Express, Discover, CareCredit, MasterCard, and Visa.
Authorization
I hereby authorize the veterinarian of Holly Tree Animal Hospital, P.C. to examine, prescribe for, or treat the
above-described pet. I assume responsibility for all charges incurred in the care of the animal. I also understand that ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.

Signature

Sign above

Client Registration form

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