New Patient Registration Form

Owner Name*

Co-Owner Name

Address*

Street Address Address Line 2 City State ZIP Code

Email Address

Home Number

Work Number

Cell Number*

Co-Owner Work Number

Co-Owner Cell Number

Name of Previous Clinic

Phone

Military

Yes
No

Senior

Yes
No

Recommended by Whom?

Place of Employment

First Pet

Select One:*

Dog
Cat

Pet Information

Name	Breed	Microchip#	Date of Birth	Color	Sex	Spayed or Neutered

Date of Vaccinations

Rabies	DA2P	Parvo	Corona	Bordatella

Date of Vaccinations

Rabies	FELV	ENT-FVRCP	FIP

Second Pet

Select One:

Dog
Cat

Pet Information

Name	Breed	Microchip#	Date of Birth	Color	Sex	Spayed or Neutered

Date of Vaccinations

Rabies	DA2P	Parvo	Corona	Bordatella

Date of Vaccinations

Rabies	FELV	ENT-FVRCP	FIP

Third Pet

Select One:

Dog
Cat

Pet Information

Name	Breed	Microchip#	Date of Birth	Color	Sex	Spayed or Neutered

Date of Vaccinations

Rabies	DA2P	Parvo	Corona	Bordatella

Date of Vaccinations

Rabies	FELV	ENT-FVRCP	FIP

I/we hereby authorize the veterinarians to examine, prescribe for, or treat my pets (s). I/we assume full responsibility for all charges incurred in the care of this/these animal(s). I/we also understand that these charges will be paid in full at the time of release and that a deposit may be required for certain surgical treatments or other procedures.

Critical Care Authorization - Your pet has been presented to AV Veterinary Center with a critical or life threatening condition. We require authorization to initiate and or continue critical care in an attempt to stabilize your pet. This initial stabilization may include an IV (intravenous catheter and fluids, emergency bloodwork, X-rays and possible CPR). We estimate the initial cost of stabilization to be $600 - $850 The veterinarian on duty will speak to you a soon as possible. At that time they will provide you with an initial prognosis and estimate of costs for continued diagnostics and care. I authorize AV Veterinary Center to continue emergency treatment of my pet and understand critical care deposit is required in advance.*

Yes
No

Medical CPR: I authorize obtaining an airway, breathing for my pet, external chest compressions and the administration of drugs and fluids in an attempt to re-establish circulation and respiration, if needed. I understand that charges may be incurred.*

Yes
No

Type Signature

Name

This field is for validation purposes and should be left unchanged.

First Pet

Second Pet

Third Pet

Location

Office Hours