RegistrationHuman’s Name Spouse / Other Address Street Address City State / Province / Region ZIP / Postal Code Employer PhoneHome PhoneCell PhoneOtherEmail Address In Case of Emergency Please call: Name: PhoneHow did you hear about us? Drive by Yellow Pages Advertisement Person Who? Pet Health HistoryPet’s Name Date of Birth MM slash DD slash YYYY Approx. Age Type of Animal Dog Cat Guinea Pig Ferret Hamster Other Species Sex: Male Female Neutered Male Spayed Female Breed Color Microchipped Yes No Current Heartworm preventative, flea preventative, and Medications:Describe your Pet’s DietPrevious Veterinarian PhonePlease check any symptoms or problems that you have noticed about your pet: Bad Breath Bleeding Gums Breathing Problems Coughing Diarrhea Behavior Problems Eyes Red or Itchy Gagging Lack of Appetite Limping Loss of Balance Scooting Scratching Seems Depressed Shaking Head Sneezing Increased Thirst Inappropriate urination Vomiting Weakness Weight Problems Other Type here Add More (Pet Health History) Pet Health HistoryPet’s Name Date of Birth MM slash DD slash YYYY Approx. Age Type of Animal Dog Cat Guinea Pig Ferret Hamster Other Species Sex: Male Female Neutered Male Spayed Female Breed Color Microchipped Yes No Current Heartworm preventative, flea preventative, and Medications:Describe your Pet’s DietPrevious Veterinarian PhonePlease check any symptoms or problems that you have noticed about your pet: Bad Breath Bleeding Gums Breathing Problems Coughing Diarrhea Behavior Problems Eyes Red or Itchy Gagging Lack of Appetite Limping Loss of Balance Scooting Scratching Seems Depressed Shaking Head Sneezing Increased Thirst Inappropriate urination Vomiting Weakness Weight Problems Other Type Here Add More ( Pet Health History ) Pet Health HistoryPet’s Name Date of Birth MM slash DD slash YYYY Approx. Age Type of Animal Dog Cat Guinea Pig Ferret Hamster Other Species Sex: Male Female Neutered Male Spayed Female Breed Color Microchipped Yes No Current Heartworm preventative, flea preventative, and Medications:Describe your Pet’s DietPrevious Veterinarian PhonePlease check any symptoms or problems that you have noticed about your pet: Bad Breath Bleeding Gums Breathing Problems Coughing Diarrhea Behavior Problems Eyes Red or Itchy Gagging Lack of Appetite Limping Loss of Balance Scooting Scratching Seems Depressed Shaking Head Sneezing Increased Thirst Inappropriate urination Vomiting Weakness Weight Problems Other Type Here Authorization I hereby authorize the Bartram Trail Veterinary Hospital to examine, prescribe for, and/or treat my pet(s). I assume responsibility for all charges incurred in the care of the animal. I understand that these charges must be paid when services are rendered and a deposit may be required for some treatments. Media Release We enjoy sharing photos and videos of our patients and their families on social media and occasionally on print materials, advertising, and signage for the hospital. By agreeing below, you grant Bartram Trail Veterinary Hospital, its representatives, and employees the right to take photographs and/or videos of your pet, and to copyright, use, and publish the same in print and/or electronically. We appreciate your consent, as well as respect if you choose not to participate. Please select one option below(Required) Bartram Trail Veterinary Hospital may take photos and/or videos of my pet(s) Bartram Trail Veterinary Hospital may NOT take photos and/or videos of my pet(s) Signature of OwnerDate MM slash DD slash YYYY
