Registration Form – Haiku Veterinary Clinic

New Client Registration Form

Owner's Name
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 Country
Day-Time Phone*
Evening Phone
Mobile Phone
Email*
Enter Email Confirm Email
Co-owner's Name & Contact #
Name
First Last
Phone
How did you find out about our practice?
- Clinic Location
- Ko'olau Pets
- Petco
- Personal Referral
- Internet Search / Website
- Yellow Pages
- Clinic Sign
- Newspaper / Print Media
- Other
If Other, please specify:
If Personal Referral, is there someone we can thank for this referral?
Please use this area to give us any other relevant information about yourself or your family
Pet Information
Pet's Name*
Species*
or if other species
Breed (if known)
Color
Date of Birth or Age (if known)
Special Identification (tattoo, microchip, etc.)
Sex
Previous Veterinary Practice (if any)
Previous Veterinarian (if any)
Date of last vaccines (if known)
MM
DD
YYYY
What vaccines were given at this time
Is your pet on any medication or supplement?
- Yes
- No
If Yes, please list the medication or supplement
What food does your pet eat?
Does your pet have allergies or drug reactions?
- Yes
- No
If Yes, please list the allergies and reactions
Are there any current or past medical conditions of which we should be aware?
- Yes
- No
If Yes, please comment on the condition(s) and indicate if they are current or past conditions
Please use the following box to give us any other relevant information about your pet
I hereby authorize the staff of Haiku Veterinary Clinic to render any treatment which is deemed necessary to my pet(s)health while in the custody of the hospital. I understand that in the event of unusual emergency circumstances, the staff will make every attempt to contact me or my designated representative before, if time permits, proceeding with treatment. I understand that I will be financially responsible for all emergency procedures including the Estimate of Charges provided to me in person or over the telephone. I understand that professional fees are to be paid at the time of service rendered and a deposit is required for all pets admitted to the hospital.
I (We) authorize HVC to obtain my pet(s) previous veterinary records from:
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
Signature

New Client Registration Form

Owner's Name

Co-owner's Name & Contact #

Pet Information