CLEVELAND VETERINARY CLINIC, P
Cleveland Veterinary Clinic
400 N McLean Blvd
South Elgin, IL 60177
(847) 697-4066
Client Registration Form
CLIENT NAME:
SPOUSE NAME:
ADDRESS:
CITY:
ZIP:
COUNTY:
PHONE: HOME: CELL: OTHER_____________:
EMAIL ADDRESS (TO ACCESS YOUR PET’S MEDICAL RECORDS 24 HOURS A DAY):
ARE YOU OVER 65 YEARS OLD? Y / N
HOW DID YOU HEAR ABOUT US? (Circle one):
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OUR WEBSITE
DRIVE BY
REFERRAL, REFERRED BY_________________________________________________
OTHER __________________________________________________________________
|Pet #_1______________________________ |Pet #_2______________________________ |
|Name: |Name: |
|Date of Birth: |Date of Birth: |
|Species: Dog / Cat / Other _______________ |Species: Dog / Cat / Other _______________ |
|Breed: |Breed: |
|Sex: Male / Female Spayed / Neutered Y / N |Sex: Male / Female Spayed / Neutered Y / N |
|Color: |Color: |
I certify that I am the owner or authorized agent of the owner of the pet(s) described above and can make medical decisions on their behalf. I understand that payment is expected at the time of service and I am responsible for any legal fees incurred in collecting any unpaid balances.
SIGNATURE _______________________________________ DATE ___________________________
SIGNATURE OF PERSON PRESENTING THIS
PET FOR TREATMENT IF OTHER THAN OWNER _______________________________________________________
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