Crystal Springs Pet Hospital is pleased to provide you with a variety of forms that can simplify the process of caring for your pet. Just select from the available form on the menu.
CLIENT REGISTRATION
Today’s Date: ________________
Driver’s License or I. D. Card Number: __________________ Expiration date:____________
Name:____________________________________________ Referred by: ________________
Last First Middle
Address:_____________________________________________________________________
Street number and name City State Zip Code
Occupation: ____________________
Employer:________________________________________
Name
_____________________________________________
Address City State Zip
Telephone Numbers (please include area code): e-mail: ______________________
| Home:(__)___-_____ |
Work:(__)___-_____ |
Cell:(__)___-_____ |
| Home Fax:(__)___-_____ |
Work Fax:(__)___-_____ |
Pager:(__)___-_____ |
Alternate Contact: ________________________________________________________________
Name Phone
[ ] Spouse [ ] Partner [ ] Co-owner [ ] ______ Name: __________________________
Last First Middle
Address: _________________________________________________________________________
Street number and name (if different than above) City State Zip Code
Occupation: ____________________
Employer: ____________________________________
Name
_____________________________________________
Address City State Zip
Telephone Numbers: (please include area code)
| Home:(__)___-_____ |
Work:(__)___-_____ |
Cell:(__)___-_____ |
| Home Fax:(__)___-_____ |
Work Fax:(__)___-_____ |
Pager:(__)___-_____ |
Alternate Contact:___________________________________________________________
Name Phone
PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE PERFORMED
- In admitting my pet(s) for diagnostics, treatment, or surgery, I authorize the veterinarians of Crystal Springs Pet Hospital and their support staff, to administer such treatment and/or perform such diagnostic or surgical procedures as deemed necessary.
- It is understood that an estimate of charges will be given for services. No guarantee or assurance can be made as to the results that may be obtained.
- Further, I understand that a deposit of 50% is required before services are performed and I assume full financial responsibility for all charges incurred by my pet. I realize that these charges may exceed a given estimate if complications arise. I understand that I will be contacted prior to treatment, if possible, should complications occur.
Signature: _________________________ Signature:_________________________
Sacramento Veterinary Surgical Services, Inc. Revised 7/2/98
PATIENT REGISTRATION
Client Name: ________________________________________________________
Chart ID #: __________
| [ ] Dog |
[ ] Cat |
[ ] Bird |
[ ] Rabbit |
[ ] Reptile |
[ ] Rodent |
[ ] Other_______ |
Pet’s Name: _____________________________ Breed: _______________________
Birthdate (approx. if unknown): __________ [ ] Male [ ] Neutered [ ] Female [ ] Spayed
Color/Markings: _________________________ Identification: ____________________
Vaccination history (please check those that apply and provide the date of the last vaccination):
[ ] Rabies [ ] Distemper-Parvo [ ] Feline upper respiratory [ ] Feline Leukemia
________ _________________ ___________________ ______________
Date Date Date Date
* * * * * * * * * * * * * *
| [ ] Dog |
[ ] Cat |
[ ] Bird |
[ ] Rabbit |
[ ] Reptile |
[ ] Rodent |
[ ] Other_______ |
Pet’s Name: ______________________________ Breed: ________________________
Birthdate (approx. if unknown): __________ [ ] Male [ ] Neutered [ ] Female [ ] Spayed
Color/Markings: _________________________ Identification: ____________________
Vaccination history (please check those that apply and provide the date of the last vaccination):
[ ] Rabies [ ] Distemper-Parvo [ ] Feline upper respiratory [ ] Feline Leukemia
________ _________________ ___________________ ______________
Date Date Date Date
* * * * * * * * * * * * * *
| [ ] Dog |
[ ] Cat |
[ ] Bird |
[ ] Rabbit |
[ ] Reptile |
[ ] Rodent |
[ ] Other_______ |
Pet’s Name: ______________________________ Breed: ________________________
Birthdate (approx. if unknown): __________ [ ] Male [ ] Neutered [ ] Female [ ] Spayed
Color/Markings: _________________________ Identification: ____________________
Vaccination history (please check those that apply and provide the date of the last vaccination):
[ ] Rabies [ ] Distemper-Parvo [ ] Feline upper respiratory [ ] Feline Leukemia
________ _________________ ___________________ ______________
Date Date Date Date
* * * * * * * * * * * * * *
| [ ] Dog |
[ ] Cat |
[ ] Bird |
[ ] Rabbit |
[ ] Reptile |
[ ] Rodent |
[ ] Other_______ |
Pet’s Name: ______________________________ Breed: ________________________
Birthdate (approx. if unknown): __________ [ ] Male [ ] Neutered [ ] Female [ ] Spayed
Color/Markings: _________________________ Identification: ____________________
Vaccination history (please check those that apply and provide the date of the last vaccination):
[ ] Rabies [ ] Distemper-Parvo [ ] Feline upper respiratory [ ] Feline Leukemia
________ _________________ ___________________ ______________
Date Date Date Date
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