Bayshore Veterinary Clinic of L’Anse

438 Main Street

L’Anse, MI  49946

906-524-5678

Feline 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)

 

Name of Spouse/Partner _________________________ Home Phone _______________

 

Other Phone___________________________ (business, employment, relative, neighbor)

 

Referred by Whom _____________________ Previous Veterinarian? ________________

 

Animal Information

 

Name ______________________ Breed ______________________ Color ____________

 

 

Birth Date _______________    Male           Neutered            Female             Spayed

 

Date of Last:

            1. Distemper Vaccination (FVRCPC) ____________________________________

            2. Rabies Vaccination ________________________________________________

            3. Feline Leukemia Vaccination (FELV) __________________________________

            5. Has your cat ever been tested for Feline Leukemia? ______ Results _________

            6. Has your cat ever been dewormed? ______ When? ______________________

7. Last Stool Exam (for Intestinal Parasites) _______________________________

 

Are there any chronic medical problems of which we should be aware? _______________

            Please explain ______________________________________________________

 

Is your cat currently on any medications? (If so, please list them) ___________________

_______________________________________________________________________

 

Your cat is INDOORS __________ % and/or OUTDOORS __________ %

 

Do you have any other cats? _____ How many? _____ Dogs? _____ How many? _____

 

What brand of cat 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.

 

Please sign to consent to treatment: _____________________________ Date: ____________

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For Office Use: Identification Verified    Date_________  Initials_________