New Client / Patient Registration | Northshore Humane Society

Client / Owner Information

Client First Name

Client Last Name

Street Address

Street Address Contd.

City

State

Zip Code

Primary Phone Number

Alternate Phone

Email Address

Preferred Contact Method

Pet Information

How many pets would you like to schedule?

Pet 1 Information

Species (Dog / Cat)

Pet's Name

Age or Date of Birth

Breed

Color

Sex (Male or Female)

Is your pet spayed or neutered?

Yes

Is your pet current on vaccinations?

What prevention(s) is your pet currently using?

Preexisting Medical Conditions or Allergies

Please list any concerns you would like addressed during your visit.

Do your pet have a history of vaccine reactions?

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

Is your pet current on vaccinations?

What prevention(s) is your pet currently using?

Preexisting Medical Conditions or Allergies

Please list any concerns you would like addressed during your visit.

Do your pet have a history of vaccine reactions?

Pet 3 Information

Species 3 (Dog / Cat)

Pet's Name 3

Age or Date of Birth 3

Breed 3

Color 3

Sex (Male or Female) 3

Is your pet spayed or neutered?

Yes

Is your pet current on vaccinations?

What prevention(s) is your pet currently using?

Preexisting Medical Conditions or Allergies

Please list any concerns you would like addressed during your visit.

Do your pet have a history of vaccine reactions?

Pet 4 Information

Species 4 (Dog / Cat)

Pet's Name 4

Age or Date of Birth 4

Breed 4

Color 4

Sex (Male or Female) 4

Is your pet spayed or neutered?

Yes

Is your pet current on vaccinations?

What prevention(s) is your pet currently using?

Preexisting Medical Conditions or Allergies

Please list any concerns you would like addressed during your visit.

Do your pet have a history of vaccine reactions?

Previous Veterinary Clinic

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

Yes

Name of Previous Veterinary Clinic

Previous Clinic Phone or Email

Previous Medical Records

Upload requirements

Client Signatures

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

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

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

How did you hear about our vet clinic?

TV Appearance

Radio Interview

Word of Mouth

Google

Newspaper

Other

None of the above