New Client / Patient Registration | Northshore Humane Society

Owner Information

Client First Name

Client Last Name

Street Address

City

State

Zip Code

Primary Phone Number

Cell Phone

Email Address

Secondary Contact Name

Phone Number

Email Address

Pet Information

How many pets would you like to schedule?

Species (Dog / Cat)

Pet's Name

Age or Date of Birth

Breed

Color

Sex (Male or Female)

Is your pet spayed or neutered?

Yes

Does your pet have any ongoing medical conditions, allergies or concerns?

Yes

Please Explain

What is the reason for your pet's appointment?

Pet 2 Information

Species 2 (Dog / Cat)

Pet's Name 2

Age or Date of Birth 2

Breed 2

Color 2

Sex (Male or Female) 2

Is your pet spayed or neutered?

Yes

Does your pet have any ongoing medical conditions, allergies or concerns?

Yes

Please Explain

What is the reason for your second pet's appointment?

Date & Time of Requested Appointment

Alternative Date & Time of Requested Appointment

Previous Veterinary Clinic (if any)

May we contact your previous vet to obtain your pet's medical history?

Yes

I understand that all fees are due at the time that services are rendered. Northshore Humane Society does not offer billing.

Yes

Client Initials

I understand that if I neglect to pick up my pet within 10 days of the pick up date, NHS assumes that the pet is abandoned and is hereby authorized to take possession of the pet and make any decisions as may be deemed best and necessary for its care.

Yes

Client Initials

I give permission for my pet's photos and videos to be use on all forms of social media including Facebook, YouTube, and Twitter.

Yes

Client Initials

I certify that I am the person responsible for authorizing and paying for all medical procedures and expenses for listed pets. (sign below)

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How did you hear about our vet clinic?

TV Appearance

Radio Interview

Word of Mouth

Google

Newspaper

Other

None of the above

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