New Client Registration Form
Owner’s Name: Spouse/Other: Date: Address:
City: State: Zip: Home Phone # Cell Phone # Employer Name: Work # Email for appointment reminders: Driver’s License # (required) State of License Name and phone number of the Person to contact in case of an EMERGENCY: Does anyone in the household have a suppressed immune system? Patient InformationPet’s Name: Sex: Neutered MaleIntact MaleSpayed FemaleIntact FemaleApprox. Date of Birth or Age: Species: Dog Cat Other: Breed: Color: List of medications this pet is currently on: Reason for visit: Previous Veterinarian(s) where past records can be obtained: Social Media Permission: I allow Harbor Animal Hospital to take photographs/videos of my pet to post on Harbor Animal Hospital's social media pages. Accept YESNOI assume responsibility for 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.*All returned checks will be charged a $25.00 insufficient funds bank fee. Any account left unpaid will be sent to collections and charged an additional collection fee of 33 1/3%.
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Your legal name
Your email address
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Document Name: New Client Registration Form
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