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Canine Registration Form

Bayshore Veterinary Clinic of L’Anse

438 Main Street

L’Anse, MI  49946                               


Canine Patient Registration Form


Name of Owner ___________________________________________________________

                                 Last                                             First                                     Middle


Home Address ___________________________________________________________



                                  City                                             State                                   Zip

e-mail address___________________________________   


Drivers License/SS# ____See Attached_____ (This information is needed in case of anesthetic or prescription of certain controlled medications)            


Home Phone _______________       Name of Spouse/Partner _______________________


Other Phone___________________________ (business, employment, relative, neighbor)


Referred by Whom _____________________ Previous Veterinarian? ________________


Animal Information


Breed ______________________ Name ______________________ Color ____________



Birth Date _______________   Male            Neutered                Female            Spayed


Date of Last:

            1. Distemper Parvovirus Vaccination (DHLPP-CV)___________________________

            2. Rabies Vaccination ________________________________________________

            3. Lyme Vaccination _________________________________________________

            5. Kennel Cough Vaccination (Bordetella) ________________________________

            6. Heartworm Check (Blood Test) ____________________ Results ___________

            7. Has your dog been on Heartworm Medication? __________________________

            8. Last Stool Exam (for Intestinal Parasites) _______________________________

            9. Has your dog ever been dewormed? ______ When? ______________________


Are there any chronic medical problems of which we should be aware? _______________

            Please explain ______________________________________________________


Is your dog currently on any medications? (If so, please list them) ___________________



Do you have any other dogs? _____ How many? _____ Cats? _____ How many? _____


What brand of dog food do you currently feed? __________________________________


Form of Payment

                             Cash _____ Personal Check _____ Visa/Mastercard/Discover _____


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.


Date:_________    Please sign to consent to treatment:___________________________


For Office Use: Identification Verified    Date__________ Initials_______

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