Lone Mountain Animal Hospital - A full service small ...
WELCOME
New Client Registration
Last Name___________________________________First Name_________________________
Spouse (Co-Owner) First Name_______________________________Last Name_____________
Street Address__________________________________________________________________
City_______________________________State_____________________Zip Code___________
Home Phone:________________ Cell Ph:_____________Co-Owner Cell Ph:_______________
Email Address:________________________________________________________________________
Pet Portal sign up – 24/7 access to your pet’s medical records and our online store
(We do not sell this information)
Name of previous hospital________________________________________________________
How did you learn about our hospital?_______________________________________________
Your Pet’s Information
1st Pet 2nd Pet 3rd Pet 4th Pet
|Name | | | | |
|Species | | | | |
|Breed | | | | |
|Color | | | | |
|Sex |F SPAY |F SPAY |F SPAY |F SPAY |
| |M NEUTER |M NEUTER |M NEUTER |M NEUTER |
|Age/DOB | | | | |
Authorization:
I/We hereby authorize the veterinarian to examine, prescribe for or treat my pet(s). I/we assume full responsibility for all charges incurred in care of this/these animal (s). I/we also understand that charges will be paid in full at the time of discharge and that a deposit may be required for certain surgical treatments or other procedures.
Signature of owner:_______________________________Date:_______________
Signature of co-owner:_______________________________Date:____________
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