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Registration
Owner 1 First Name
Owner 2 First Name
Owner 1 Last Name
Owner 2 Last Name
Street Address
Street Address Line 2
City
Region/State
Postal / Zip code
Country
Owner 1 Email
Owner 1 Phone
Owner 2 Email
Owner 2 Phone
How did you hear about us?
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Number of Dogs
Number of Cats
Number of Other Animals
Pet History
Name of Pet
Type of Animal
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Breed
Sex
*
Undetermined
Male
Neutered
Female
Spayed
Color
Age
Vaccination History
Please check any symptoms that you have noticed abut your pet
Behavioral Problems
Bleeding Gums
Breathing Problems
Coughing
Diarrhea
Eye Bulging or Bloodshot
Gagging
Lack of Appetite
Limping
Loss of Balance
Scooting
Scratching
Seems Depressed
Shaking Head
Sneezing
Thirst or Urination Increased
Vomitting
Weakness
Other
Current Medications
Describe Your Pet's Diet
Medical Records if Available
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I hereby authorize the veterinarian to examine, prescribe for, and/or treat the above described pet. I assume full responsibility for all charges incurred for the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment.
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