Name: Elwood Animal Clinic
Telephone: +1-
Price range: $$

Owner*

First Last

EMAIL*

ADDRESS*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

CELL PHONE NUMBER*

RELATIVE OR FRIEND TO BE CONTACTED IN CASE OF EMERGENCY DURING YOUR ABSENCE:

NAME

First Last

CELL PHONE NUMBER

ADDRESS

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

PET’S NAME*

SEX*

DOB*

SPAY/NEUTERED?*

YES
NO

SPECIES*

CAT
DOG

BREED*

COLOR*

OWNED SINCE*

WHERE PURCHASED/FOUND*

ANY KNOWN ALLERGIES OR PAST MEDICAL PROBLEMS*

VACCINATION HISTORY:

PLEASE INDICATE DATE THE VACCINE WAS GIVEN.

DHLPP(Distemper-Parvo)

CORONA

BORDETELLA

RABIES

LYME(Borrelia)

WAS YOUR CAT EVER TESTED FOR FELINE LEUKEMIA?

YES
NO

RESULTS

FELV(Feline Leukemia)

FVRCPC

FIP

RABIES

WHERE DOES YOUR PET SPEND IT’S TIME :*

Indoors only
Indoors/outdoors
Outdoors only

CURRENT MEDICATIONS: (Prescribed /Over The Counter)

PARASITE PREVENTION:

FLEA PREVENTION:

DIET FED:

I UNDERSTAND THAT PROFESSIONAL FEES ARE TO BE PAID AT THE TIME THAT THEY ARE RENDERED. I AUTHORIZE TREATMENT FOR THE PATIENT NAMED ABOVE AND ACCEPT RESPONSIBILITY FOR THE CHARGES INCURRED IN THIS HOSPITAL. (AGENT / OWNER Signature)*

E-SIGNATURE (You agree your electronic signature is the legal equivalent of your manual signature on this form.)

PHOTO CONSENT

WE RESPECT YOUR PRIVACY AND WILL NEVER USE YOUR PET’S PHOTO WITHOUT YOUR PERMISSION. NAMES OR IDENTIFYING CLIENT INFORMATION WILL NOT BE SHARED.

DO WE HAVE YOUR PERMISSION TO TAKE PHOTOS OF YOUR PET FOR USE ON OUR WEBSITE, SOCIAL MEDIA, OR CLINIC MATERIALS?*

YES, I CONSENT TO THE USE OF MY PET'S PHOTO.
NO, I DO NOT CONSENT TO THE USE OF MY PET'S PHOTO.

Date*

Consent to Release Veterinary Records*

I DO consent to the release of my pet’s records as outlined above.
I DO NOT consent to the release of my pet’s records.

I authorize Elwood Animal Clinic to release my pet’s medical records to other veterinary hospitals, specialists, or animal care providers upon request, as deemed necessary for continuity of care. I understand that records may be sent via fax, email, or other secure electronic means. I also authorize the release of vaccine history and relevant medical information to boarding facilities, grooming salons, training facilities, or city/county animal control, when required.

Email

This field is for validation purposes and should be left unchanged.

OWNER/PATIENT REGISTRATION FORM

RELATIVE OR FRIEND TO BE CONTACTED IN CASE OF EMERGENCY DURING YOUR ABSENCE:

VACCINATION HISTORY:

PHOTO CONSENT

Our Location

Come Visit Us

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OWNER/PATIENT REGISTRATION FORM

RELATIVE OR FRIEND TO BE CONTACTED IN CASE OF EMERGENCY DURING YOUR ABSENCE:

VACCINATION HISTORY:

PHOTO CONSENT

Our Location

Come Visit Us

Have Questions? We’ll Reply Quickly.

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