PALM CITY ANIMAL MEDICAL CENTER
CLIENT REGISTRATION
DR. REX SENTELL
DR. MIKE WIEGAND
DR. PAUL WOLFF
DR. MATTHEW SCHMIDT
DR. ELIZABETH JOLIN
DR. MATTHEW KRECIC
THANK YOU FOR GIVING PALM CITY ANIMAL CLINIC THE OPPORTUNITY TO CARE FOR YOUR PET(S). SO THAT WE
MAY BECOME BETTER ACQUAINTED, PLEASE COMPLETE THE FOLLOWING:
CLIENT INFORMATION
DATE
NAME
SPOUSE'S NAME
ADDRESS
CITY
PHONE
CELL
ST
ZIP
SPOUSE'S CELL PHONE
EMAIL ADDRESS
BEST TIME TO REACH YOU
HOW DID YOU BECOME AWARE OF OUR CLINIC? ( ) DROVE BY ( ) YELLOW PAGES
PREVIOUS CLIENT
PERSONAL RECCOMENDATION, WHOM MAY WE THANK?:
PATIENT INFORMATION
PET #1
NAME
BREED
DATE OF BIRTH
COLOR
SEX; SPAY OR NEUTERERD
VACCINATION HISTORY- DOG
RABIES
DISTEMPER
CORONA
BORDETELLA
FECAL (STOOL SAMPLE)
HEARTWORM TEST
HEARTWORM PREVENTION
VACCINATION HISTORY - CAT
RABIES
DISTEMPER
LEUKEMIA TEST
LEUKEMIA VACCINE
FECAL (STOOL SAMPLE)
IS YOUR PET?
x
PET #2
PET #3
DATE
DATE
DATE
DATE
DATE
DATE
A MEMBER OF THE FAMILY
( ) CHILDREN'S PET
( ) BACKYARD PET
ANY PREVIOUS SERIOUS ILLNESSES OR SURGERIES?
ANY ALLERGIES TO VACCINATIONS OR MEDICATIONS?
IS YOUR PET ON ANY SPECIAL DIETS OR MEDICATIONS?
ALL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.
IF WE REQUIRE OUTSIDE AGENTS TO COLLECT ANY DEFAULT AMOUNT, ALL COLLECTION, FINANCE CHARGES,
ATTORNEY'S FEES, AND COSTS WILL BE YOUR OBLIGATION AS WELL AS ALL PRICIPLE AMOUNTS DUE.
SIGNATURE