Gold Beach Veterinary Clinic (541) 247-2513

Established Patients Only. This form is for current clients of Gold Beach Veterinary Clinic only. If you have not yet been seen at our clinic, please call us at (541) 247-2513 to schedule your first appointment before filling out this form.

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Welcome to Gold Beach Veterinary Clinic

Thank you for trusting us with your pet’s care.

Client Information

Today's DateOwner (Last Name First)Mailing AddressCity

StateZip Code

Home PhoneCell PhoneEmail AddressCo-Owner/SpouseCo-Owner Phone NumberHow did you learn about this practice?Primary Reason for VisitNumber of Pets in HouseholdSpecies Type(s) in Household

Pet Information

Pet's NameSpecies

DogCatOther

If Species is Other, please specifyGender

MaleFemale

AgeBirth DateBreedSpayed/Neutered?

YesNo

At What Age (if spayed/neutered)Color(s)Reason for Obtaining Pet

CompanionBreedingShowProtection

If Other, please specifyObtained From

FriendBreederPet ShopShelter/Humane Society

If Other, please specifyDietGrain Free/High Protein Diet?

YesNo

List Current MedicationsRecords: Clinic/Shelter NameRecords: Phone #

Authorization

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet.

I assume responsibility for all charges incurred in the care of the animal.

I also understand that ALL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.

I have read and agree to the authorization above, and I am the person responsible for this pet’s care and charges.

Signature (type your full legal name)Date

We look forward to caring for you and your pets!