Registration Form (Koolau Puppy) – Haiku Veterinary Clinic

Please fill out the registration form below:

Owner's Name*
First Last
Have you been to our clinic before?
- Yes
- No
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*
Phone*
Additional Contact (Name)
First Last
Additional Contact (Phone)
Spouse Email
Former or Active Military?
- Yes
- No
Puppy Information
Puppy’s Tag Information:
Breed*
Birthdate*
MM
DD
YYYY
Tag Number*
Invoice Number*
I authorize my pets records be released to another clinic/hospital or pet insurance company that is requesting records*
- Yes
- No
In the event of an emergency and pet is referred to an emergency clinic, I authorize my pets records be released to the clinic.*
- Yes
- No

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Haiku Veterinary Clinic Online Clinic Registration Form