Aurora Veterinary Clinic

305 Aurora Commons Circle
Aurora, OH 44202

(330)562-5100

www.auroravet.com

New Client Registration Form

Which clinic is your appointment at? (required)

Aurora Veterinary Clinic
Mantua Veterinary Clinic
Streetsboro Veterinary Clinic


What date is your appointment? :
Reason for appointment? (required)

Name of responsible party (required)
First Name (required)
Last Name (required)
Name of second responsible party
First Name
Last Name
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
E-Mail Address (required) :
Primary Phone (required)
Phone TypePhone Number (required)
Phone
Phone TypePhone Number
Spouse / Other phone number
Phone TypePhone Number
Preferred method of contact

Email
Text
Cell


Cell phone provider

Verizon
AT&T
Sprint
TMobile
N/A


When is the best time to reach you?

Morning
Afternoon
Evening


How did you hear about us? Please select ONE

Sign
Live in area
Aurora Kennel
Website
Facebook
Yellow Pages
Client Referral


Who may we thank for referring you?

Emergency contact name & number

Does your pet travel outside of our area? If yes, where?


PRIVACY STATEMENT: Your privacy is of the utmost importance to us. Without your written consent, we cannot release any information related to you our your pet(s) to any individuals not listed on this form. We will not discuss, release or fax any information regarding any of your pets to anyone other than those individuals authorized on this form.
Name
First Name
Last Name
FINANCIAL AUTHORIZATION (please check all boxes) (required)
I assume responsibility for all charges incurred in the care of the above animal(s)
I understand that ALL charged must be paid, in full, at the time of service
I understand that, in some cases, a deposit may be required prior to treatment
Electronic signature (required)
First Name (required)
Last Name (required)
Pet's name:

Pet's date of birth:

Species

Dog
Cat
Other


Sex
Male
Neutered
Female
Spayed
Unsure
Breed:

Color:

Name of previous veterinarian:

May we contact your previous vet for medical records?

Yes
No


Please list below ALL current medication(s), supplements and over-the-counter products given to you pet(s).

Name of heartworm prevention

Name of flea/tick prevention

Are there any other pets in your household?

Yes
No


If yes, please list all pets below:

Name/brand of pet food currently offered (Please note whether canned or dry):

How much does your pet eat daily?

My pet is fed:

Once daily
Twice daily
More than 3 times daily
Free feed


How often do you change brands of food?

Never
Monthly
Weekly
Other


Do you feed your pet table food (scraps)?

a
b
c


Type of treats given to your pet:

Approximately how many treats do you give per day?

1-2
3-4
5-6
>6


To the best of my knowledge the above information is true and accurate

I hearby authorize the veterinarian(s) and staff at Aurora Animal Care Center, Inc. to examine, prescribe for or treat the described pet(s).
Electronically sign your name (required)
First Name (required)
Last Name (required)

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