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Pet
Registration and History
Hoschton Animal
Hospital
3434 Georgia Highway 53
Hoschton, Georgia 30548
706-654-1111
Thank you for giving us the opportunity to care
for your pet. We'll be happy to answer any questions you have about your pet's
health. To insure the best care possible, please print this form and take the
time to fill in this form completely, before you come to the clinic.
Thank you!!
Owner:
_______________________________________ email: _________________________
Address: ________________________________________________________________
________________________________________________________________
Spouse: ______________________________________ email: __________________________
Home Phone: _________________________ Work Phone:
______________________
Spouse Work Phone: ___________________
Emergency Contact Name: _________________________________________________
Emergency Contact Phone:_________________________________________________
How did you learn of our clinic? ______ Yellow Pages
_____ Recommendation
______
Sign
_____ Other: _____________________________________
If recommended, by whom? _________________________________________________
Number of pets: Dogs___________ Cats ______________ Other
(specify) __________
Reason for visit:
___________________________________________________________
_________________________________________________________________________
_________________________________________________________________________ |
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Name of pet:
___________________________ ___ Dog ___
Cat ___ Other: _______
Breed: ______________________ Color: _______________ Birthdate:
_______________
_____ Male _____
Neutered _____ Female
_____ Spayed
Vaccination History (Date and type of last vaccinations)
___________________________
_________________________________________________________________________
_________________________________________________________________________
Please check any symptoms or problems that you have noticed about your
pet:
___ Behavior
Problems
___ Bleeding Gums
___ Breathing Problems
___ Coughing
___ Diarrhea
___ Eye Bulging or Bloodshot
___ Gagging |
___ Lack of
Appetite
___ Limping
___ Loss of Balance
___ Scooting
___ Scratching
___ Seems Depressed
___ Shaking Head |
___ Sneezing
___ Thirst and/or Urination Increased
___ Vomiting
___ Weakness
___ Other: ____________________
_____________________________ |
Pet's current medications:
___________________________________________________
_________________________________________________________________________
Describe your pet's diet:
____________________________________________________ |
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| I hereby authorize the
veterinarian to examine, prescribe for, or treat the above described pet.
I assume responsibility for all charges incurred in the care of this
animal. I also understand that these charges will be paid at the time of
release and that a deposit may be required for surgical treatment.
Signature of Owner:
_____________________________________________________
Method of Payment: ___
Cash ___ Check ___
MasterCard ___ VISA
___ Other: ____________________________________________ |
P.O. Box 608, Hwy. 53
Hoschton, Georgia 30548
Phone: 706-654-1111
Business Hours
Mon- Fri: 8:30am - 6:00pm
Closed Noon-2:00pm
Sat: 8:30am - Noon
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