Registration Form in Waipahu, HI

Registration Form
Thank you for choosing our pet clinic. We pride ourselves in offering compassionate care for your pet and we are looking forward to caring for your pet’s needs for many years to come. To ensure the best care possible, please take the time to fill in this form completely. Thank you!
Owner's Name:*
First Last
Address:*
City:*
Zip code:*
Email Address:*
Employer:
Home Phone:*
Work Phone:
Cell Phone:
Spouse:
Spouse's Cell Phone:
Emergency Contact:
Phone:
How did you learn of our clinic?
- Yellow Pages
- Sign
- Internet
- Recommendation
Pet Health History
Name of Pet:
Species:
- Dog
- Cat
Sex:
- Male
- Neutered
- Female
- Spayed
Breed:
Color:
Birthdate:
Microchipped?
- Yes
- No
If yes, please enter microchip #:
Appointment Date
MM slash DD slash YYYY
Payment Policy
Full payment is required at the time of service. We accept cash, check, Visa, Mastercard, and Discover credit cards. Deposits are required on medical, trauma, surgical and emergency cases where hospitalization is necessary. There is a charge for missed appointments that have not been cancelled with 24 hour advance notice.
Authorization
I hearby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility of all charges incurred in 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.
Signature*
Date:*
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Comments
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Registration Form

Pet Health History

Payment Policy

Authorization

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Registration Form

Registration Form

Pet Health History

Payment Policy

Authorization

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