Owner’s InformationName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date* MM slash DD slash YYYY Owner’s Driver’s License # & State* Daytime Phone #*Is it Primary Evening Phone #*Is it Primary Cell Phone #*Is it Primary Email* Co-Owner's Name* Phone Number*How did you find out about our practice?* Google / Internet Search Social Media Clinic Location / Signage Personal Referral Other Personal Referral: Someone we should thank?* Other:* What Social Media Platforms do you use?* Facebook Instagram Tik Tok Twitter Snapchat Pinterest I DONOT use any platforms Pet’s InformationPet’s Name* Pet’s Name at the Time of Adoption* (applies to pets adopted from Woof Gang Rescue)Species*CatDogSex*MaleNeutered MaleFemaleSpayed FemaleBreed* Color/Markings* Date of Birth / Age* Microchip Not microchipped Other Medical InformationPrevious Veterinary Practice (if any)Do we have your permission to collect records?* Yes No Is your pet on any medication or supplements? Please list:*What type of food does your pet eat? Please List*Does your pet have any allergies or drug reactions? Please List:*Are there any current or past medical conditions we should be aware of?* Yes No If yes, please explain:*Are there any other pets in the home?* Yes No If yes, please list:*Do you have another pet you would like to register with our practice today?* Yes No 2nd PetPet’s Name* Pet’s Name at the Time of Adoption* (applies to pets adopted from Woof Gang Rescue)Species*CatDogSex*MaleNeutered MaleFemaleSpayed FemaleBreed* Color/Markings* Date of Birth / Age* Microchip Not microchipped Other Medical InformationPrevious Veterinary Practice (if any)Do we have your permission to collect records?* Yes No Is your pet on any medication or supplements? Please list:*What type of food does your pet eat? Please List*What type of food does your pet eat? Please List*Are there any current or past medical conditions we should be aware of?* Yes No If yes, please explain:Are there any other pets in the home?* Yes No If yes, please list:*Photo Consent:We love social media! Do we have your permission to share your pet(s)’ image/video/story on social media, our website & other forms of related media? Your name and personal information will never be shared* YES! You have my permission No, I do not consent Pet Health Savings PlanSay Goodbye to full price with our In-House Savings Plan! Not only will you save 20% on every invoice at every visit, your pet will also receive a FREE Rabies vaccine! YES! Tell me more. I’d like more information on your Pet Health Savings Plan No Thank You. I am not interested in learning more about the plan at this time. Treatment ConsentUpon signing this agreement, I certify I am the Owner/Authorized Agent of the above pet(s) and have authorization to consent to treatment if and when needed. I authorize the American Veterinary Hospital to examine, prescribe for and/or treat the above pet(s).* Upon signing this agreement, I certify I am the Owner/Authorized Agent of the above pet(s) and have authorization to consent to treatment if and when needed. I authorize the American Veterinary Hospital to examine, prescribe for and/or treat the above pet(s). * I recognize that financial concerns should be discussed PRIOR to exams & treatment.* I recognize that financial concerns should be discussed PRIOR to exams & treatment. * I understand I am entitled to ask for and be provided with a written estimate of fees regarding services and/or products prior to services being performed.* I understand I am entitled to ask for and be provided with a written estimate of fees regarding services and/or products prior to services being performed. * I assume full responsibility for all charges incurred and understand these incurred charges are to be paid, IN FULL, at the time the services are rendered.* I assume full responsibility for all charges incurred and understand these incurred charges are to be paid, IN FULL, at the time the services are rendered. * Agent’s Signature*Date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
