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East Side Veterinary Clinic

Client Registration

Date_________________

Owner________________________________S.S.N.______________________

Address___________________________________________Apt. #____________

City___________________________________Zip________________

Owner’s Date of Birth____________________________

Home Phone (         _)                                            Cell (_____) _______________

Work Phone (_____)_______________________

Email Address___________________________________

            I would like reminders sent by:     ( _____) postcard   (_____) email

Employer Name/Address______________________________________________

Spouse_________________________________________________

Cell (____)_____________________Work phone (____)_____________________

Pet Information

Name___________________________(     ) Dog        (    ) Cat 

(    ) Male        (    ) Female                   (    ) Spayed        (    ) Neutered

Breed____________________Color__________________Birthdate____________

Previous Vet__________________________________

Current Medication(s)_________________________________________________

PLEASE FILL OUT OTHER SIDE OF THIS FORM

How did you find us?

(    ) Client referral.   May we have their name so we can thank them?

                        ______________________________________________

(    ) Directory                (    )Website                    (     )Advertisement

Permission

East Side Veterinary Clinic  (    ) MAY     (    ) MAY NOT  use my pet’s photo on social media networks.

Authorization

I hereby authorize the veterinarian to examine, prescribe for and treat the above described pet.  I 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 treatment.

(Signed)____________________________________Date____________

Method of Payment (please check all that apply):

(     ) Cash          (     ) Visa          (     ) MasterCard          (     ) Discover

(     ) AmEx          (     ) Check; S.S.N. or current Driver’s License required

To prevent the spread of infectious diseases and parasites, hospitalized animals must be current on all vaccines and free from external and internal parasites.

Exclusive Offer

New clients receive 10% OFF first exam. ( please visit special offers page for more details)

Office Hours

Day
Monday7:306:00pm
Tuesday7:306:00pm
Wednesday7:306:00pm
Thursday7:306:00pm
Friday7:306:00pm
Saturday8am12:30pm
SundayClosedClosed
Day
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
7:30 7:30 7:30 7:30 7:30 8am Closed
6:00pm 6:00pm 6:00pm 6:00pm 6:00pm 12:30pm Closed