Owner's Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone Number *

(###)

###

####

Secondary Phone Number

(###)

###

####

Date of Birth *

If you are not sure, please estimate.

MM

DD

YYYY

Date of Birth

If you are not sure, please estimate

MM

DD

YYYY

Date of Birth

If you are not sure, please estimate.

MM

DD

YYYY

Date of Birth

If you are not sure, please estimate.

MM

DD

YYYY

Do your pets have previous veterinary records? *

Yes

No

I'm Not Sure

I declare I am the lawful owner of all listed pets. I hereby authorize the veterinarian(s) and staff of High Country Veterinary Hospital to examine and treat my pet(s) to meet the highest standards of quality care. I assume responsibility for all charges incurred in the care of this animal. I acknowledge that my pet's medical information will not be released to anyone not indicated on this form without my express verbal and/or written permission, and understand High Country Veterinary Hospital reserves the right to refuse the release or disclosure of medical records if the account has an outstanding balance *

By signing this document, I declare that all information is true and correct to the best of my knowledge.