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.)

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.

Name

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:

Our Location

Come Visit Us

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We’ll Reply Quickly.

OWNER/PATIENT REGISTRATION FORM

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

VACCINATION HISTORY:

Our Location

Come Visit Us

Have Questions? We’ll Reply Quickly.

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