RAINIER VETERINARY HOSPITAL
815 Rainier Avenue South
Seattle, WA 98144
(206) 324-4144
Thank you for the opportunity to care for your pet. Please take a moment to complete this information sheet.
CLIENT REGISTRATION
Date: ______________
Owner’s Name: _______________________________________ Spouse/Other: ____________________
Address: _____________________________________________________________________________
City/State: _________________________________________
Zip Code: ________________________
Home Phone: (____) ___________ Work Phone: (____) ___________ Cell Phone: (____) ____________
How did you hear about us? _____________________________________________________________
E-mail: ______________________________________________________________________________
PATIENT REGISTRATION
Pet’s Name: ___________________________
Species:
Canine
Feline
Breed: ________________________________ Color: __________________________
Sex:
Male
Female
Spayed/Neutered:
Date of Birth: __________________________ Microchip:
No
No
Yes
Yes, Number: ______________
MEDICAL HISTORY
Allergies:
No
Chronic Conditions:
Yes, Please explain: _________________________________________________
No
Medications/Supplements:
Special Diet:
No
Yes, Please explain: __________________________________________
No
Yes, Please explain: ___________________________________
Yes, Please explain: ________________________________________________
PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE PROVIDED
In admitting my pet for diagnostics, treatment, or surgery, I authorize the veterinarians of Rainier Veterinary Hospital
and their support staff to administer such treatment and/or perform such diagnostic or surgical treatment as deemed
necessary. It is understood that I may request an estimate of charges for any services. No guarantee or assurance can be
made as to the results that may be obtained. Furthermore, I realize that these charges may exceed a given estimate if
complications arise. I understand that I will be contacted prior to treatment, if possible, should complications arise. I
assume financial responsibility for all charges incurred for services provided and understand that full payment is
required upon request.
SIGNATURE OF OWNER OR RESPONSIBLE AGENT: _________________________________________________________
FOR OFFICE USE ONLY
Canine:
_____ Rabies
_____ DHPP
_____ Lepto
_____ Bordetella
Date: ___________
Date: ___________
Date: ___________
Date: ___________
Feline
_____ Rabies
_____ FVRCP
_____ FeLV
Date: ___________
Date: ___________
Date: ___________