Twin Cities Veterinary Clinic

47303 Healing Court
Soldotna, AK 99669

(907)262-4581

www.twincitiesvet.com

Client Record Sheet (MALE)
Twin Cities Veterinary Clinic 
Soldotna, Alaska

Client Record Sheet (Male) Form

Owner: (required)

Phone: (required)

Co-Owner:

Co-Owner Phone:

Address (required)
Street Address (required)
City (required)
,		State / Province (required)
Zip / Postal Code (required)
Employer: (required)

Work Phone: (required)

Co-Owner Employer:

Co-owner Work Phone:

Other contact numbers:

Email Address: (required)

Pet Information
Pet Name: (required)

Pet Date of Birth: (required)

Breed: (required)

Color/Markings: (required)

Species: (required)
Canine
Feline
Other
Is your pet neutered? (required)
Yes
No
Previous Veterinarian:

May we request records if needed?
Yes
No
Last Vaccinations:
DOG'S DHPP/Rabies/Bordetella:

CAT'S FVRCP/Rabies/FELV

Does your pet have any known illnesses, allergies or drug sensitivities? (required)
Yes
No
If yes, please list:

Has your pet ever had any seizures? (required)
Yes
No
Is your pet currently receiving any medications? (required)
Yes
No
If yes, please list:

If new client, how did you find us? (required)
Phone book
Sign
Referral
If referral, by whom?

Unless prior arrangements have been made, payment is due at the time of services.
How the account is to be paid:
Cash
Check
Credit Card
Authorization and Consent:
(required)
I am the owner of the above named animal or am responsible for the patient and have authorization to execute this consent.
I hereby authorize treatment of this animal and performance of such surgical or therapeutic procedures as you determine to be indicated and the use of anesthetics as you deem advisable.
It is agreed that past due accounts are subject to $5/month service charge and/or 1.5% monthly interest in addition to all costs of collection, including reasonable filing and attorney fees.
I am responsible for maintaining current addresses and phone contact information with Twin Cities Veterinary Clinic.
Any animal will be considered abandoned if within 10 days of written notice to remove the animal(s) mailed to the address above, the animal is not removed, and that upon such abandonment, Twin Cities Veterinary Clinic may destroy, sell or otherwise dispose of the animal without prejudice to its claim for fees or services needed.
Signature (please type your first and last name): (required)

Date: (required)


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