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Home
About
Our Team
Reviews
Photo Gallery
Careers
Contact
Services
Pet Vaccines
Pet Dental Care
Pet Surgery
Pet Laser Surgery
Pet Laser Therapy
View All Services
Resources
Online Forms
FAQs
Our App
Client Savings
Book Appointment
Welcome Form
Thank you for giving us the opportunity to care for your pet. We will 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 out this form completely. Thank You!
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Welcome Form
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REGISTRATION
Todays Date
Owner
*
Spouse/Other
*
Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
--- Select country ---
Afghanistan
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 (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
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
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
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
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Home Phone
*
Work Phone
*
Cell Phone
*
has your registration information changed since you got this new pet? If you selected yes please fill out our updated registration information.
*
Yes
No
Email
*
Occupation
*
Employer
*
PET HEALTH HISTORY
Name of Pet's
*
Pet Type
*
Dog
Cat
Alpaca
Other
Sex
*
Spayed/Neutered
*
Breed
*
Age
*
Color
*
LAST VACCINATION DATES
Dogs
Distemper
*
Parvo
*
Bordatella
*
Rabies
*
Is your dog on a preventative heartworm medication?
*
CATS
FVRCP
*
FELV
*
Rabies
*
ALPACAS: CD & T
*
Areas your pet has lived besides the Chino Valley/Prescott Area?
*
Problems we should be aware of: chronic illness, allergies, medications etc
*
We at Circle L Animal hospital strive to provide your pet(s) with uncompromising care, in a warm safe environment. Our regular office hours are by appointment: Monday to Friday 8:00am-6:00pm, closed Tues. from 12:00pm-1:30pm, and open Saturday from 8:30am-2:00pm. A doctor is available on call 24 hours, however we do not have an attendant on the premises 24 hours. Should you need a Doctors service after our regular office hours, call 771.7564 and the Doctor on call will be paged. If the Doctor is involved in another emergency, there may be a sight delay in getting back to you, but the Doctor will return your call!
AUTHORIZATION
PAYMENT IS EXPECTED AT THE TIME OF SERVICES. Cash, Check, Visa, Mastercard, Amex, Discover and Care Credit are accepted. We provide quotes for routine services on request. In estimating costs for emergency services, we will keep you informed if any changes. In the event that an account is not paid full in due, it will bear interest at the rate of 24% per anum. Client further agrees to pay cost of collection and reasonable attorneys fees if this matter is referred an attorney for collection.
Signature
*
Clear Signature
Date
*
Drivers License #
*
Exp. Date
*
DOB
*
Where did you hear about us?
How did you hear about Circle L Animal Hospital
*
Circle L Employee
Newspaper
Monthly Special, Coupon, Smart Shopper /Savy Ad
Circle L Website
Google
Facebook
Highway Sign/Drove By
Current Client Referral
Phone Book
Special Event
Dex Online
Other, Please Specify:
If you were referred by a friend/neighbor, please provide us with their name and telephone number below so that we can apply a $30:00 Client Referral Credit to their account. Learn more about our referral program below!
Name
Phone
HAVE YOU HEARD ABOUT OUR REFERRAL PROGRAM?
Earn credit and help pay for your veterinary care. Tell a friend about us and encourage them to come in for a visit . All they need to do is present this "referral card" to us and upon completion and payment for their office visit you will be credited $30:00 towards products and service for your next visit to 4 Paws Rehabilitation.
New Client Name:
Pets Name
*
I was referred by:
Date Of Visit
Staff Initial
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