New Client Registration Form – Pet Authority Animal Hospital

Client Registration Form

Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.

Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.

Owner's Name
Name*
First Last
Drivers License Number*
Home Phone Number*
Cell Phone Number
Work Phone Number
Date of Birth*
Date Format: MM slash DD slash YYYY
Address
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Enter Email Confirm Email
Preferred method of contact is?*
Hold CTRL to select multiple options
Co-owner's Name & Contact #
Name
First Last
Home Phone Number
Cell Phone Number
Work Phone Number
How did you find out about our practice?
- Clinic Location
- Personal Referral
- Internet Search / Website
- Yellow Pages
- Clinic Sign
- Newspaper / Print Media
- Other
If Other, please specify:
If Personal Referral, is there someone we can thank for this referral?
Please use this area to give us any other relevant information about yourself or your family
Pet Information
Pet's Name*
Species*
or if other species
Breed (if known)
Color
Date of Birth or Age (if known)
Special Identification (tattoo, microchip, etc.)
Sex
Previous Veterinary Practice (if any)
Previous Veterinarian (if any)
Date of last vaccines (if known)
Date Format: MM slash DD slash YYYY
What vaccines were given at this time
Click yes or no If you wish to have your pets photos shared.
Click yes or no if you consent to share any medical history (including vaccination dates) with outside facilities.*
Please use the following box to give us any other relevant information about your pet

Location

4588 West Walton Blvd,
Waterford, MI 48329

(248)-673-1288
info@petauthority.net

Hours of Operation

Monday – Friday
7:30am – 6:00pm

Saturday – Sunday
closed

Get Directions Contact Us

Client Registration Form

Owner's Name

Address

Co-owner's Name & Contact #

Pet Information

Location

Hours of Operation