New Client Registration

Homer Veterinary Clinic PC

326 Woodside Avenue
Homer, AK 99603

(907)235-8960

www.homervet.com

New Client Registration Form

Client Information
Owner Name

Spouse/Partner Name:

Owner Phone
Phone TypePhone Number
Spouse/Partner Phone:
Phone TypePhone Number
Mailing Address
Street Address
City
,
State / Province
Zip / Postal Code
Physical Address
Street Address
City
,
State / Province
Zip / Postal Code
Email (for billing & reminder purposes): :
Date of Birth (for controlled substances): :
Patient Information:
Pet #1: Name

Species
Dog
Cat
Other
Is your pet:
Spayed
Neutered
n/a
DOB or Age:

Breed:

Color

Name of previous Veterinarian:

May we contact previous veterinarian for your pet's medical records?
Yes
No
n/a
Is your pet on any medications, supplements or special diets?

Has your pet experienced any allergic reaction to prior vaccinations or medications?

Pet #2
Name

Species
Dog
Cat
Other
Is your pet:
Spayed
Neutered
n/a
DOB or Age:

Breed:

Color:

Name of previous Veterinarian:

May we contact previous veterinarian for your pet's medical records?
Yes
No
n/a
Is your pet on any medications, supplements or special diets?

Has your pet experienced any allergic reaction to prior vaccinations or medications?

Are there any additional details you would like us to know about your pets?

Authorization:
Authorization: I am the owner of the animal(s)named above or am responsible for him/her/them and have authorization to execute this consent. I hereby authorize the diagnosis and treatment of this(ese) animal(s) and the performance of such surgical or therapeutic procedures determined to be indicated and the use of drugs/anesthetics/devices deemed advisable by the veterinarian staff. Payment is due at the time of service. Cash, check (exception health certificates), Visa, Mastercard, Discover, American Express and Care Credit are all accepted. A 1.5% per month service charge is applied to all unpaid accounts. A pet is considered abandoned if, within 5 days of written notice to do so, the pet is not claimed nor alternative arrangements made with clinic staff. If abandoned, the clinic may rehome or, if deemed medically necessary, euthanize the pet and fees for services provided caring for the pet will still be payable.
Authorize
I agree
I disagree

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