Client Registration

OWNER INFORMATION

Last Name*

First Name*

Address

Street Address City State / Province / Region ZIP / Postal Code

Primary Phone*

Cell
Home
Work

Secondary Phone*

Cell
Home
Work

Email Address*

Enter Email Confirm Email

Employer Name

Phone

SPOUSE/CO-OWNER/PARTNER

Last Name*

First Name*

Address

Street Address City State / Province / Region ZIP / Postal Code

Primary Phone

Cell
Home
Work

Secondary Phone

Cell
Home
Work

Email Address

Employer Name

Phone

In case of emergency and we are unable to contact you,who should we contact ?

Name

Phone

How Did You Hear About Us?*

Please Specify

Promotion Code

Tell us about your family

Number of Pets

Dogs

Cats

Children ?

None
Yes

Ages

Source of Pet:

Other

Do you take your pet…(check all the apply )

on walks
to the park
to groomers/daycare
to run errands/stores
on family vacations
camping/hiking
Strickly Indoor
Strictly Outdoor
Indoor/Outdoor

Reason for visit

Pet's food is

PET HEALTH HISTORY

Name of Pet*

Dog
Cat

Male
Female

Breed*

Color*

Neuter/Spay*

Yes
No

Birth date

Age*

Date of Last Vaccines*

Previous Veterinarian*

Known Allergies*

Pet’s current medications/supplements*

Please check any symptoms or problems you have noticed about your pet or that your pet has experienced in the past.*

Other

AUTHORIZATION

I hereby authorize the veterinarian to examine, treat and prescribe for the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that all charges must be paid at the time services are rendered and that a deposit may be required for surgical treatment or hospitalization.

Do we have permission to share your records with:

Other Hospitals/Clinics
Groomers/Daycares
Pet Insurance

Authorization*

Date

Opt Out :

Check this box if you do NOT want you or your pets picture or name displayed on our website, Facebook, Twitter or any other promotional/educational material. We love sharing our patient pictures with other animal lovers!
Encanto Pet Clinic accepts most major Credit Cards, Care Credit, Cash, or Personal Local Check with valid ID.

Phone

This field is for validation purposes and should be left unchanged.