Veterinary Center for Birds & Exotics ● 709 Bedford Road, Bedford Hills, NY 10507 ● (914) 864-1414
Owner’s Name: ___________________________ Email address: __________________________________
Street address:___________________________________________________________________________
City: __________________________________________ State: ____________ Zip Code: ______________
Home Phone: ______________________________ Cell Phone: ___________________________________
Employer: _____________________________________ Work Phone: ______________________________
How did you hear about us? _______________
If Internet search, which Search Engine ?______________
Did you find us through a general listing on the Internet or an Internet Ad? ______________
Emergency Contact Person: ________________________ Emergency Contact Phone: _________________
Pet’s Name: _________________________ Date of Birth/Age: ________________________________
Type of Animal (Circle one): Bird Rabbit Ferret Guinea pig Chinchilla Rat Mouse Hamster Gerbil Degu
Snake (indicate species) _________________________ Lizard (indicate species)___________________
Turtle (indicate species) __________________________Tortoise (indicate species) _________________
Amphibian (indicate species) ______________________ Other _________________________________
Color/Markings: _________________________ Sex (Circle one): M F Neutered Spayed Unknown
If you have a ferret, the date of last rabies vaccination is _________________________. If vaccination was not performed
at the Veterinary Center, we request documentation proving vaccination elsewhere. Ferrets are required by New York
state law to be vaccinated annually. If your ferret has not been vaccinated for rabies in the past year, the Veterinary
Center staff can vaccinate your pet at the time of examination.
Consent to Photograph/Video
I give Veterinary Center for Birds & Exotics the irrevocable right and permission to copyright, use, publish,
exhibit, and distribute photographs/videos of me and/or my pet (circle one, or both), as well as my name
and/or my pet's name (circle one, or both), in order to advertise, publicize, and promote Veterinary Center for
Birds & Exotics services, and educate the general public, through the use of social media including, without
limitation, on Veterinary Center for Birds & Exotics website, Facebook, Flickr, Youtube, Twitter, and in
newsletters and brochures. I waive any right to approve the final product(s) in which any such
photographs/videos may appear. This release is binding on me, my heirs, legal representatives, and assigns.
Signature: _________________________________ Date: _______________________________
CLIENT REGISTRATION FORM (MUST be 18 or older to fill out)