ARLINGTON CAT CLINIC – REGISTRATION FORM

1
What day and time is your appointment?* This field is required.
Date
Month
Day
Year
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
AM
AM
PM
2
What day and time is your appointment?* This field is required.
Appointment Date
Appointment Time
3
Client Information*(Must be 21 years of age or older)
Owner Name
Spouse Name
Cell Phone
Home Phone
Email
Pet Name
4
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
5
For check writing privileges, please provide your* This field is required.
Driver’s License #
6
Pet Information
Pet Name
Sex
SPAYED
NEUTERED
SPAYED or NEUTERED ?
Date of Birth or Age
Breed
Color
Front only
All 4 paw declaw
NOT DECLAWED
DECLAWED?
7
Signature
Clear
8
Vaccination HistoryPlease indicate date or month and year of vaccine
Distemper
Rabies
Leukemia
Other
Feline Leukemia test (Felv) - Date
Feline Leukemia test (Felv) - Result
FIV test? - Date
FIV test? - Result
9
How old was your cat when you acquired it?
Does your cat go outside?
Breeder
Shelter
Store
Stray
Private Home
Where did you acquire your cat?
10
How many other pets are in your household?
Cats
Dogs
Other
11
What brand of food do you feed?
Dry
Canned
Prior illnesses or surgeries?
Any known allergies or vaccine reactions?
Microchip #
12
Is your cat* This field is required.
Declawed (Front)
Declawed (All 4 Paws)
Not Declawed
Type option 4
13
Is your cat
Just a pet
A member of the family
14
How did you become aware of us?* This field is required.
Yellow pages
Hospital Sign
Internet
Magazine
15
I grant Arlington Cat Clinic permission to post my cat’s photo, and story on social media
Yes
No
16
If yes, (signature required)
Clear
17
***PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE RENDERED*****

In admitting my pet(s) for diagnostics, treatment, or surgery, I authorize the doctors of Arlington Cat Clinic, Ltd. and their support staff, to administer such treatment and /or perform such diagnostic or surgical procedures as deemed necessary. It is understood that an estimate of charges will be given for hospitalizations and surgeries. No guarantee or assurance can be made as to the results that may be obtained. Further, I realize that these charges may exceed a given estimate if complications arise. I understand that I will be contacted prior to treatment, if possible. I agree to pay Arlington Cat Clinic, Ltd. at the time services are rendered. If the account goes delinquent; no payment in 30 days, the account will be assessed a 2.00% billing fee on the outstanding balance (24% yearly). I further agree if the account is transferred to collections, I will be responsible for all the costs necessary to collect this balance including collection fees, costs, and filing fees. If a check is returned non-sufficient funds, a minimum of $25.00 will be added to the amount owed.
18
Signature
Clear
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