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COUNTRYSIDE ANIMAL CLINIC
CLIENT REGISTRATION
Client Name (if over 18 yrs. old):
______________________________________________________________________________________
(Last) (First) (Middle)
Address: ______________________________________________________________________________
(Number) (Street) (Apt #)
______________________________________________________________________________________
(City) (State) (Zip Code)
Home # _________________________________ Work # ______________________________________
Cell # ___________________________________ Email Address: ______________________________
Driver’s License Number: _______________________ Date of Birth: ___________________________
(Required for check writing privileges)
Employer: _____________________________________________________________________________
(Name) (Address) (Phone Number)
Referred by____________________________________________________________________________
***********************************************************************************************************************
Other Person(s) Authorized to make Medical and Financial Decisions:
Name: ___________________________________Driver’s License # ___________________________
Address: ___________________________________________________________________________
_____________________________________________________________________________________
Home # _____________________ Work # ______________________Cell #________________________
Relationship to Client: ___________________________ Date of Birth: __________________________
Employer: _____________________________________________________________________________
(Name) (Address) (Phone Number)
*************************************************************************************************************************
FINANCIAL RESPONSIBILITY AGREEMENT
Full payment is expected at time of service. I understand that if my account balance is not paid in a timely fashion, I will be responsible for not only the balance due but also for any collection and/or reasonable attorney fees that are incurred in the attempt to collect this debt. Outstanding debts will be assessed with an interest fee of 1.5% per month (18% per annum). Countryside Animal Clinic reserves the right to report any overdue accounts to the Credit Bureaus.
__________________________ _________________________________ ___________________
Print Name Signature Date
__________________________ _________________________________ ___________________
Print Name Signature Date
PET INFORMATION
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PET # 1
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PET # 2
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PET # 3
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PET # 4
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PET’S NAME:
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DATE OF BIRTH:
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SPECIES: CANINE/FELINE
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BREED:
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COLOR:
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SEX:
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SPAYED/NEUTERED?
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LAST RABIES VACC:
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LAST DISTEMPER VACC:
(DAPP/FVRCP)
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LAST HEARTWORM TEST:
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TYPE OF HEARTWORM PREVENTATIVE USED:
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TYPE OF FLEA & TICK CONTROL USED:
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LAST FELINE LEUK VACC:
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LAST FELV/FIV TEST:
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LAST LYMES VACC:
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LAST BORDETELLA VACC:
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LAST FECAL EXAM:
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CHRONIC MEDICAL ISSUES:
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LONGTERM MEDICATIONS:
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