New Client Registration Form Name* First Last Phone*Name First Last PhoneAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email* During regular office hours how would you generally prefer we contact you: First Phone Number Second Phone Number EmailHow did you hear of our clinic? Sign/Walking By Referral Recommendation AdvertisingIf recommended / referred, pleease tell us by whom?Pet Health HistoryName of pet*SpeciesDogCatBreed*Color*Age or DOB*SexMaleMale-NeuteredFemaleFemale-SpayedPatient Records Yes, I would like you to request a copy of my pet(s) previous records. No, I will call my previous vet to have them fax a copy of my pet(s) records to you.My previous vet is:Reason for visit:Authorization: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 professional fees are due at the time services are rendered and that a deposit may be required for surgical treatment.We will gladly prepare a written estimate if you desire. Please ask any staff member.SignatureDate Date Format: MM slash DD slash YYYY Video-Photo ReleaseI grant Sunset Hill Veterinary & Rehabilitation Center, its representatives and employees the permission to take pictures and/or video of me and/or my pet(s), and to use, copyright, and/or publish the same in print and/or electronically.I agree that Sunset Hill Veterinary & Rehabilitation Center may use such pictures and/or video of me and/or my pet(s) with or without the name(s) of my pet(s) and/or my name and for any lawful purpose, including, for example, such purposes as educational, publicity, advertising, and Web content. The above may take photos of me and/or my pet(s) The above may NOT take photos of me and/or my pet(s)Pet name:*SignatureDate Date Format: MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
