New Client Registration in Surrey, BC

Owner's Name:

Co-Owner Name:

Address:

City:

Postal Code:

Home Phone:

Cell Phone:

Co-owner phone

Email:

Previous Veterinary Hospital

Do you have pet insurance?

Insurance Company

Policy/ Customer #

#1 Pet's Name

Species

Breed

Sex

Female Male

Color

Are they Spayed or Neutered?

Yes No

Date Of Birth

Are their vaccines up to date?

Yes No

Does your pet have any known health conditions or allergies?

#2 Pet's Name

Species

Cat Dog Other

Breed

Sex

Female Male

Color

Are they Spayed or Neutered?

Yes No

Date Of Birth

Are their vaccines up to date?

Yes No

Does your pet have any known health conditions or allergies?

#3 Pet's Name

Species

Cat Dog Other

Breed

Sex

Female Male

Color

Are they Spayed or Neutered?

Yes No

Date Of Birth

Are their vaccines up to date?

Yes No

Does your pet have any known health conditions or allergies?

Date

Authorization:

I accept that all procedures will be performed to the best of the abilities of the staff at City Petcare Hospital & Urgent Care. I understand that no guarantee or warranty has been made regarding the results that may be achieved. I understand that I assume financial responsibility and will pay for all services upon my pet’s discharge from City Petcare Hospital & Urgent Care.

OPTIONAL: City Petcare Hospital & Urgent Care, its representatives and employees have my permission to photograph my pet for the purpose of documenting treatment progress. I also permit the use of said photographs and case information for educational purposes, to copyright, use and publish the same in print and/or electronically. I agree that City Petcare Hospital & Urgent Care may use such photographs of me and/or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content. Confidentiality is assured and all other personal information will remain in confidence.

Signature

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