New Client Registration Client Information Client Name (Pet Owner) Co-Owner's Name (If Applicable) Address City State Zipcode Country -- Select Country -- AFGHANISTAN ALAND ISLANDS ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA AND HERZEGOVINA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORY BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO CONGO, THE DEMOCRATIC REPUBLIC OF THE COOK ISLANDS COSTA RICA CÔTE D'IVOIRE CROATIA CUBA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS (MALVINAS) FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTHERN TERRITORIES GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUERNSEY GUINEA GUINEA-BISSAU GUYANA HAITI HEARD ISLAND AND MCDONALD ISLANDS HOLY SEE (VATICAN CITY STATE) HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN, ISLAMIC REPUBLIC OF IRAQ IRELAND ISRAEL ITALY JAMAICA JAPAN JERSEY JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA, DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA, REPUBLIC OF KUWAIT KYRGYZSTAN LAO PEOPLE'S DEMOCRATIC REPUBLIC LATVIA LEBANON LESOTHO LIBERIA LIBYAN ARAB JAMAHIRIYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAO MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA, FEDERATED STATES OF MOLDOVA, REPUBLIC OF MONACO MONGOLIA MONTENEGRO MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY, OCCUPIED PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT BARTHÉLEMY SAINT HELENA SAINT KITTS AND NEVIS SAINT LUCIA SAINT MARTIN SAINT PIERRE AND MIQUELON SAINT VINCENT AND THE GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SERBIA SERBIA AND MONTENEGRO SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS SPAIN SRI LANKA SUDAN SURINAME SVALBARD AND JAN MAYEN SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN TAJIKISTAN TANZANIA, UNITED REPUBLIC OF THAILAND TIMOR-LESTE TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM UNITED STATES UNITED STATES MINOR OUTLYING ISLANDS URUGUAY UZBEKISTAN VANUATU VENEZUELA VIETNAM VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. WALLIS AND FUTUNA WESTERN SAHARA YEMEN ZAMBIA ZIMBABWE Home Phone Number Cell Phone Number Work Phone Number Email Address Emergency Contact Emergency Number How did you hear about us Saw Sign/Drove By/Location Employee/Family/Friend (Name if known) Advertisement (Newspaper/Valpak/Coupon/Etc.) (Type if known) Online/Website: (Facebook/AzPetVet.com/Hospital Website/Google/Etc.) (Site if known) Rescue Organization / Other Animal Hospital (AHS/Animal Control/Etc.) (Name if known) Other (Please Explain) Patient Information Pet Name Date of Birth Breed Color Species Dog Cat Other Other Species Type Gender Male Neutered Male Female Spayed Female Reason for visit Medical History Dog Rabies Date DHPP Date Bordetella Date Heartworm Test Date Fecal Test Date Microchip Number Medical History Cat Rabies Date FVRCP Date FELV Date FELV/FIV Test Date Fecal Test Date Microchip Number What food does he/she eat? Monthly Dewormer Flea / Tick Control Current Medications Previous Medical Problems/Surgeries/Allergies Have you traveled or do you plan on traveling with your pet? Yes No If Yes, please name Location Is There A Clinic We May Contact To Receive Any Previous History On The Patient? Clinic Name Clinic Phone Number Add Additional Pet? Yes No Second Patient Information Pet Name Date of Birth Breed Color Species Dog Cat Other Other Species Type Gender Male Neutered Male Female Spayed Female Reason for visit Medical History Dog Rabies Date DHPP Date Bordetella Date Heartworm Test Date Fecal Test Date Microchip Number Medical History Cat Rabies Date FVRCP Date FELV Date FELV/FIV Test Date Fecal Test Date Microchip Number What food does he/she eat? Monthly Dewormer Flea / Tick Control Current Medications Previous Medical Problems/Surgeries/Allergies Have you traveled or do you plan on traveling with your pet? Yes No If Yes, please name Location Is There A Clinic We May Contact To Receive Any Previous History On The Patient? Clinic Name Clinic Phone Number Are you a robot?
