Allentown Cat Clinic PC New Client / Cat Registration Owner Name*Spouse/OtherAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell Phone*Email* Referred ByEmergency 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*CashCheckDebitMastercardVisaDiscoverCarecredit