Bayshore Veterinary Clinic of L’Anse

438 Main Street

L’Anse, MI  49946                               

906-524-5678

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:___________________________

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For Office Use: Identification Verified    Date__________ Initials_______