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*

Email*

Referred By

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 booking fee of $50.00 per patient ($150 for surgeries) may be collected upon scheduling and 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

Electronic Signature of Owner*

Please type in your full name.

Method of Payment*