ࡱ> q` MbjbjqPqP 4X:: s|||||||8td|8nZZZZZxT$ hY#D:9|FZZFF:||ZZs000F^|Z|Z0F00||0Z 0:Z#v000##0#|0ph0jTppp::^pppFFFF $|||||| Fountain Valley Animal Hospital 311 Main Street, Security, CO 80911 PET REGISTRATION AND HISTORY To ensure the best care possible, please take time to complete this form. Owner/Responsible party:  FORMTEXT        FORMTEXT       FORMTEXT    Spouse: FORMTEXT      LastFirstMiddleName Contact Information: Address:  FORMTEXT      City:  FORMTEXT      State:  FORMTEXT   Zip:  FORMTEXT      Home Phone:  FORMTEXT      Cell Phone:  FORMTEXT      Cell Phone:  FORMTEXT       Employer:  FORMTEXT      Work Phone:  FORMTEXT      Spouse's Employer:  FORMTEXT      Work Phone:  FORMTEXT      Emergency Contact:  FORMTEXT      Phone:  FORMTEXT      Who can we thank for referring you to us?  FORMTEXT       Email Address:  FORMTEXT       Pet Information: Pet's Name:  FORMTEXT      Species:  FORMTEXT      Female  FORMCHECKBOX Male  FORMCHECKBOX Neutered or Spayed:Yes  FORMCHECKBOX  No  FORMCHECKBOX Breed:  FORMTEXT      Color:  FORMTEXT      DOB/Age:  FORMTEXT      Are vaccines current? Yes  FORMCHECKBOX  No  FORMCHECKBOX If 'No', when are they due? 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Yes  FORMCHECKBOX  No  FORMCHECKBOX  If so, please list current medications:  FORMTEXT       Are other pets in the home? # of Dogs:  FORMTEXT     # of Cats:  FORMTEXT     Other:  FORMTEXT       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 shall be paid at the time of release and that a deposit may be required for surgical treatment. Payment is due at time of services. We reserve the right to refuse/refrain from any services. By signing this form you give Fountain Valley Animal Hospital permission to have your pet s medical records faxed to our facility. For your convenience we accept payment in the form of cash, checks, Visa, Master Card, Discover and Care Credit. 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