New Client Registration

Thank you for giving us the opportunity to care for your pet(s). To help us provide the highest level of care, please take a few moments to fill out the information as accurately as possible.

Client Information

Name

Spouse / Other

Address

City

State

ZIP

Email

We will only use your e-mail address for vaccination reminders, newsletters, and in hospital promotions

Home Phone

Cell Phone

Work Phone

Spouse/Other Cell Phone

Spouse/Other Work Phone

Best way to contact

Patient Information

Patient Name

Sex

Age (yrs.)

Species

Spay/Neuter

Breed

Color

Allergies

Referral

How did you hear about us?

Whom may we thank?

Payment Information

All fees are due at time services or upon release of animal. Please let us know if you would like a written estimate before services are rendered.

Payment Method

Medical Authorization

I hereby authorize the veterinarian to examine, prescribe, and treat the above-described animal. I assume responsibilities for all charges incurred by the care of my pet, and understand that these charges will be paid in full at the time services are rendered. I also understand a deposit may be required for any surgical treatment.

Signature of Owner

Date

Yes

No

I hereby give my consent for the Animal & Bird Hospital of Clearwater to use my pet's photo(s) to be used in its publications including its website. I release them from any expectation of confidentiality for ALL PETS and myself.

Contact Us

Regular check ups with a veterinarian are important for your pet's health. Contact us today to schedule your next appointment.

Contact Us