Allentown Cat Clinic PC New Client / Cat Registration in Allentown, PA

Date

Appointment type - Please note that we are currently booking 4 - 6 weeks in advance*

Wellness
Surgery
Sick/Injured

Additional Comments:

Preferred Date #1

Preferred Time

Preferred Date #2

Preferred Time

Preferred Date #3

Preferred Time

Owner Name*

Primary Phone*

Cell Phone (If differs from above)

Spouse/Secondary Owner and Phone Number

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Referred By

Hidden

Emergency Contact and Phone Number

Name of Cat*

Birthdate of Cat*

Sex*

Male
Female

Is Your Cat Spayed or Neutered?*

Where was your cat acquired?*

Is your cat declawed?*

Is your cat?

Domesticated Short Hair
Domestic Medium Hair
Domestic Long Hair
Pure Breed

Color*

Where has your cat received previous veterinary care? (Veterinarian, shelter, rescue, etc.) Please provide name of facility. Write none if no previous medical history.*

I am responsible for having records emailed to catstaff@verizon.net or faxed to 610-398-4486 upon booking.*

Agree

I hereby authorize the veterinarian to examine prescribe for, or treat my cat. I assume responsibility for all charges incurred in the care of my cat.*

Agree

I understand that a booking fee of $50.00 per patient ($150 for surgeries) may be collected upon scheduling. Due to limited availability, this fee would be due by end of business day or the appointment will be cancelled. Additional charges will be paid at the time of release unless prior arrangements have been made. This fee will be applied to your appointment. This fee is non-refundable should you change or cancel with less than 24 hours notice.*

Agree

I further understand that I will be responsible for any additional costs or fees incurred for collection processing should this account become delinquent.*

Agree

I authorize Allentown Cat Clinic, PC to use photos and/or videos of my cat(s) for any promotional materials regarding Allentown Cat Clinic, PC programs, facilities or services. Such likenesses will not be sold to other parties. Promotional materials bearing these likenesses may be distributed for free to the public and posted on the Allentown Cat Clinic website and/or social media platforms. The Allentown Cat Clinic, PC reserves the right to use any photo or likenesses for a time period beginning when this form is signed and ending upon written request of the owner of this cat.*

I agree
I decline

Electronic Signature of Owner*

Please type in your full name.*

Method of Payment*