Allentown Cat Clinic PC New Client / Cat Registration

Owner Name*

Spouse/Other

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone*

Work Phone

Email*

Emergency Contact*

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*

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 deposit of $100.00 may be required at check-in and additional charges will be paid at the time of release unless prior arrangements have been made.*

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

Electronic Signature of Owner*

Please type in your full name.

Method of Payment*