Client and Pet Registration Form Please Download and Print the Client and Pet Registration Form or complete the electronic form below Pet OwnerTitleName* First Last Spouse or other Authorized Agent NameAddress* Street Address Apt. # City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificState ZIP Code County*Best PhoneAlternate Phone #1Please indicate who Alternate Phone #1 belongs toAlternate Phone #2Please indicate who Alternate Phone #2 belongs toEmail* OccupationEmployerIf someone recommended our hospital, please tell us so we may thank them.If not referred, how did you select our hospital?Sign/LocationInternetFacebookOtherIf other, please describe.Have you or any of your other animals ever registered with our hospital previously?YesNoPet InfoPet's NameBreedColorBirthdate Date Format: MM slash DD slash YYYY Current Age*SexMaleFemaleSpayed/Neutered (Fixed)YesNoDate of Last:Rabies ShotFecal TestHeartworm TestCanine (Date of Last)Distemper VirusParvo VirusKennel Cough (Bordetella)Feline ( Date of Last)Distemper VirusLeukemia VirusLeukemia VaccineList other shots (LEPTO, Lyme, Flu, etc.) received and date given:ShotsDate Given List current medications List Special Diets Type of Heartworm PreventiveChronic Ailments, injuries, surgeries, known drug reactions, known vaccine reactions, etc.,Type of Flea and/or Tick PreventativePermission for Client/Patient Medical Record ReleaseBy checking YES you give Clovercroft Veterinary Hospital permission to freely share information (via phone, in writing, electronically, etc.) from your pet's medical record with anyone (groomer, boarding kennel, another vet's office, etc.) calling asking for medical information. Checking YES does not mean we will share your personal information such as your address, phone number or payment information. YesNoPayment PolicyBy checking "I Agree", I understand payment is expected in full at the time services are provided. I willingly accept full financial responsibility for all procedures and treatments for pet above. I agree to make full payment for all services and products using either cash, check, debit card or Visa, MC, AmExpress or Discover credit cards. I Agree FOR IN-OFFICE USE ONLY: Signature FieldNameThis field is for validation purposes and should be left unchanged.