Welcome
Thank you for giving us the opportunity to care for your pet.  We'll be happy to answer any questions you have about your pet's health.  
To insure the best care possible, please take the time to fill in this form completely.  Thank you!
REGISTRATION
Owner Last__________________________________ First_______________________  [ ] Mr.  [ ] Mrs. [ ] Ms.

Address_________________________________ City/State________________________ Zip______________

Home Phone ____________________Work Phone_______________________Cell Phone_________________

Referral___________________________________________________________________________________

SS#__________________________ DL#______________________ E-mail_____________________________

Co-Owner____________________________ SS#________________________DL#______________________

Reason for Visit____________________________________________________________________________
PET HEALTH HISTORY
Name of Pet______________________________________  [ ] Male [ ] Neutered [ ] Female [ ] Spayed

Birthday___________________ Breed____________________ Color_________________________

                         [ ] Dog   [ ]Cat   [ ] Other___________________________

Vaccination History (date and/or last Veterinary
Clinic)__________________________________________.

Please check any symptoms or problems that you have noticed about your pet.
[ ] Thirst and/or Urination Increased                  [ ] Coughing                                     [ ] Bleeding Gums
[ ] Behavior problems                                         [ ] Diarrhea                                       [ ] Vomiting
[ ] Breathing problems                                        [ ] Eye bulging or red                      [ ] Scooting
[ ] Seems Depressed                                         [ ] Decreased Appetite                   [ ] Scratching
[ ] Sneezing                                                          [ ] Loss of balance                           [ ] Weakness
[ ] limping/lamness                                              [ ] Shaking head                               [ ] Gagging
[ ]
Other___________________________________________________________________________
Pet's currents medications_____________________________________________________________
Describe your pet's diet_______________________________________________________________
AUTHORIZATION
I hereby authorize the Veterinarian to examine, prescribe for and /or treat the above-described pet.  I assume
responsibility for all charges incurred by my pet under the care of St. Francis of Assisi VMC.  I also understand
that all charges will be paid at the time of release and that a deposit may be required for treatment.

Signature of Owner________________________________________________________________
Method of payment  [ ] cash   [ ] Check  [ ] MasterCard  [ ] Visa  [ ] CareCredit  [ ] American Express [ ] Discover
San Antonio  Veterinarian  Animal Hospital
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