Terra Linda Veterinary Hospital - Animal Registration Form

4230 Redwood Hwy	Phone: (415) 479-8535
San Rafael, CA 94903	Fax: (415) 479-0106

WELCOME

Thank you for giving us the opportunity to care for your pet. We'll be happy to answer any questions you have about your pet's health. To insure the best care possible, please take the time to fill in this form completely. Thank you!

Date_______________________

Owner's Name__________________________________________________________________________
Address_______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Home Phone__________________ Work Phone__________________ Other Phone__________________
Emergency Contact Name________________________________________ Phone___________________
How did you learn of our clinic?

[ ] Yellow Pages
[ ] Sign

[ ] Recommendation
[ ] Internet

[ ] Other___________________________________

If recommended, by whom? _______________________________________________________________
Number of pets: Dogs__________________ Cats__________________ Other (specify)_________________
Reason for visit_________________________________________________________________________

PET HEALTH HISTORY

Name of pet________________________________[   ] Dog        [   ] Cat        [   ] Other________________
Breed______________________________________ Color_________________Birthdate_____________
                                                 [   ] Male    [   ] Neutered           [   ] Female    [   ] Spayed
Vaccination history (Date and type of last vaccinations)__________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please check off any symptoms or problems that you have noticed about your pet:

[   ] Behavior Problems
[   ] Bleeding Gums
[   ] Breathing Problems
[   ] Coughing
[   ] Diarrhea
[   ] Eye Bulging or Bloodshot
[   ] Gagging

[   ] Lack of Appetite
[   ] Limping
[   ] Loss of Balance
[   ] Scooting
[   ] Scratching
[   ] Seems Depressed
[   ] Shaking Head

[   ] Sneezing
[   ] Thirst and/or Urination Increased
[   ] Vomiting
[   ] Weakness
[   ] Other___________________________
__________________________________
__________________________________

Pet's current medications_________________________________________________________________
_____________________________________________________________________________________
Describe your pet's diet___________________________________________________________________
_____________________________________________________________________________________

I hereby authorize the veterinarian to examine, prescribe for, or 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 surgical treatment.

Signature of Owner____________________________ CDL#___________________ Date______________