Allentown Cat Clinic PC New Client / Cat Registration Owner Name*Spouse/OtherAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell Phone*Work PhoneEmail* Emergency Contact*Name of Cat*Birthdate of Cat*Sex*MaleFemaleIs 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 BreedColor*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.* AgreeI 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.* AgreeI further understand that I will be responsible for any additional costs or fees incurred for collection processing should this account become delinquent.* AgreeElectronic Signature of Owner*Please type in your full name.Method of Payment*CashCheckDebitMastercardVisaDiscoverCarecredit