AHCC New Client Registration
Thank you for giving us the opportunity to care for your pets. We will be happy to answer any questions you have about your pet’s health. To insure the best care possible, please take the time to fill out this form completely. Thank you!
Registration
Owner's First and Last Name
Your answer
Spouse/Co-Owner's First and Last Name
Your answer
Address
Your answer
City
Your answer
State
Your answer
Zip
Your answer
Home Phone
Your answer
Work Phone
Your answer
Spouse Work Phone
Your answer
Email Address
Your answer
Cell Phone
Your answer
How would you prefer to be notified of vaccination reminders?
Employers Name & Address
Your answer
Spouse/Co-Owners Employer & Address
Your answer
Emergency Contact Name
Your answer
Emergency Contacts Phone
Your answer
How did you learn of our clinic?
(Check all that apply)
If recommended, whom may we thank?
Your answer
Pet 1
Name
Your answer
Birth Date
MM
/
DD
/
YYYY
Species
Breed
Your answer
Sex
Color
Your answer
Neutered/Spayed?
Vaccination History
Your answer
Long Term Problems
Your answer
Current Medications
Your answer
Pets Diet
Your answer
Pet 2
Name
Your answer
Birth Date
MM
/
DD
/
YYYY
Species
Breed
Your answer
Sex
Color
Your answer
Neutered/Spayed?
Vaccination History
Your answer
Long Term Problems
Your answer
Current Medications
Your answer
Pets Diet
Your answer
Reason for Visit
Reason for visit
Your answer
Previous Veterinarians where past records can be obtained
Your answer
Authorization
I hereby authorize Animal Health Care Center to exa mine, prescribe for and treat the pet(s) listed abo ve. I assume responsibility for all charges incurred in the care of the animal(s). I also understand that these ch arges will be paid at the time of release and that a deposit may be required for treatment
Signature of Owner or Responsible Party
Your answer
Today's Date
MM
/
DD
/
YYYY
Payment
Drivers License Number
Your answer
State
Your answer
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