Owner Information Client First Name Client Last Name Street Address Street Address Contd. City State Zip Code Primary Phone Number Cell Phone Email Address Secondary Contact Name Cell Phone Email Address Pet Information How many pets would you like to schedule? - Select -123456 Species (Dog / Cat) Pet's Name Age or Date of Birth Breed Color Sex (Male or Female) Is your pet spayed or neutered? Is your pet spayed or neutered? Yes No 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 second pet spayed or neutered? Is your pet spayed or neutered? Yes No What is the reason for your second pet's appointment? 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 third pet spayed or neutered? Is your pet spayed or neutered? Yes No What is the reason for your third pet's appointment? 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 fourth pet spayed or neutered? Is your pet spayed or neutered? Yes No What is the reason for your fourth pet's appointment? Pet 5 Information Species 5 (Dog / Cat) Pet's Name 5 Age or Date of Birth 5 Breed 5 Color 5 Sex (Male or Female) 5 Is your fifth pet spayed or neutered? Is your pet spayed or neutered? Yes No What is the reason for your fifth pet's appointment? Pet 6 Information Species 6 (Dog / Cat) Pet's Name 6 Age or Date of Birth 6 Breed 6 Color 6 Sex (Male or Female) 6 Is your sixth pet spayed or neutered? Is your pet spayed or neutered? Yes No What is the reason for your sixth pet's appointment? Date & Time of Requested Appointment (Lunch 12PM-1PM) Date & Time of Requested Appointment (Lunch 12PM-1PM): Date Date & Time of Requested Appointment (Lunch 12PM-1PM): Time Alternative Date & Time of Requested Appointment (Lunch 12PM-1PM) Alternative Date & Time of Requested Appointment (Lunch 12PM-1PM): Date Alternative Date & Time of Requested Appointment (Lunch 12PM-1PM): Time Previous Veterinary Clinic (if any) May we contact your previous vet to obtain your pet's medical history? May we contact your previous vet to obtain your pet's medical history? Yes No I understand that all fees are due at the time that services are rendered. Northshore Humane Society does not offer billing. I understand that all fees are due at the time that services are rendered. Northshore Humane Society does not offer billing. Yes Client Initials Reset 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. 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 Reset 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 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 Reset I certify that I am the person responsible for authorizing and paying for all medical procedures and expenses for listed pets. (sign below) Reset How did you hear about our vet clinic? Social Media TV Appearance Radio Interview Word of Mouth Google Newspaper Other None of the above CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit Leave this field blank
