Primary Owner *

First

Last

Secondary Owner (if applicable)

First

Last

Physical Address *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (if different)

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Mobile: *

Yes
No

Secondary Phone

Mobile:

Yes
No

Email Address *

Preferred Method of Contact for Appointment Reminders *

Text
Call
Email

Pet's Name *

Date of Birth/Age *

Species (dog, cat, etc.) *

Breed *

Color *

Sex *

Male
Female

Altered/Fixed *

Yes
No

Do you have a second pet? *

Yes
No

Pet's Name *

Date of Birth/Age *

Species (dog, cat, etc.) *

Breed *

Color *

Sex *

Male
Female

Altered/Fixed *

Yes
No

Do you have a third pet? *

Yes
No

Pet's Name *

Date of Birth/Age *

Species (dog, cat, etc.) *

Breed *

Color *

Sex *

Male
Female

Altered/Fixed *

Yes
No

Do you have a fourth pet? *

Yes
No

Pet's Name *

Date of Birth/Age *

Species (dog, cat, etc.) *

Breed *

Color *

Sex *

Male
Female

Altered/Fixed *

Yes
No

Do you have a fifth pet? *

Yes
No

Pet's Name *

Date of Birth/Age *

Species (dog, cat, etc.) *

Breed *

Color *

Sex *

Male
Female

Altered/Fixed *

Yes
No

I hereby authorize the veterinarians and staff to examine, prescribe for,and/or treat the above-described pet, as well as any additional pets added to this established account. I assume responsibility for all charges incurred in the care of this animal. I also understand that any charges will be paid for at the time when services are rendered and that a deposit may be required for hospitalization, treatment, and/or surgery.

OCEANSIDE VETERINARY HOSPITAL DOES NOT OFFER BILLING. ALL PAYMENTS ARE DUE IN FULL AT THE TIME WHEN SERVICES ARE RENDERED. PLEASE INFORM A VETERINARIAN OR TECHNICIAN IF YOU REQUIRE AN ESTIMATE BEFORE SERVICES ARE PERFORMED.

I authorize release of medical records upon request of another veterinary clinic. *

Yes
No

Signature of Owner *

Clear Signature

Date *

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