Owner and Patient Registration Form in Athens, AL

Name*

First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone*

Secondary Phone

Email*

Occupation

Work Phone

Employer

Employer's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Spouse or Co-Owner

First Middle Last

Spouse's Employer

Cell Phone

How did you hear about us? (Please check One)

Pet No.1

Pet's Name*

Type*

Dog
Cat

Breed*

Sex*

Color*

Neutered?*

Yes
No

Date Last Vaccination*

Last Rabies Vaccination*

Pet No.2

Pet's Name

Type

Dog
Cat

Breed

Sex

Color

Neutered?

Yes
No

Date Last Vaccination

Last Rabies Vaccination

I hereby authorize Eastside Animal Hospital, to examine, prescribe for, treat, or perform surgery upon the above-described pet(s). I also consent to the administrations such anesthetics as are necessary. I give my permission for photos and videos taken at Eastside Animal Hospital to be shared on their social media sites.

Furthermore, I agree to pay fees for services rendered at the time the pet is discharged from the clinic or when service is otherwise terminated. I further understand that veterinary service is provided during night time hours as necessary and is the judgment of the veterinarian. Continuous presence of qualified personnel may not be provided at all times.

Please select your preferred method of payment:*

Cash
Check
Credit/Debit

Digital signature of owner or responsible agent (write full name)*

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Name

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