"*" indicates required fields Name* First Last Co-owner Name First Last Primary Phone Number*Secondary Phone numberCo-owner PhoneAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Date of Appointment* MM slash DD slash YYYY Place of EmploymentDrivers License#*Emergency contact name and phone number:Whom may we thank for referring you?*How did you hear about us?*First Animal’s Name:*Date of Birth/Age*Species* Canine Feline Hamster Guinea Pig Bird Rabbit Reptile Other Breed:*Gender:* Male Female Spayed./Neutered?* Yes No Color:*Approximate date and type of last exam and vaccines:*Previous health conditions/concerns:*Reason for visit today:*Any Previous Records Drop files here or Select files Accepted file types: jpg, jpeg, png, doc, docx, pdf, Max. file size: 256 MB. Second Animal’s Name:Date of Birth/AgeSpecies Canine Feline Hamster Guinea Pig Bird Rabbit Reptile Other Breed:Gender: Male Female Spayed./Neutered? Yes No Color:Approximate date and type of last exam and vaccines:Previous health conditions/concerns:Reason for visit today:Any Previous Records Drop files here or Select files Accepted file types: jpg, jpeg, png, doc, docx, pdf, Max. file size: 256 MB. Communication Consent FormWe at Jefferson Animal Clinic consider you and your pet(s) as part of our family. During the year, we would like your permission to communicate with you regarding things that can be of assistance to you and your beloved pet(s). We regularly send out e-newsletters with helpful tips for the health care of your pet(s) and would love to have you follow us on Facebook and Instagram! We also want to be able to send a “thank you” for any referral you might give, a best wish for a Birthday or holiday, special offers on health care products that we recommend and of course, reminders for upcoming appointments. By receiving your permission, we know that we are communicating with you because you want to receive information that will benefit the health and well-being of your pet(s). Please check (X) below to tell us which way you are willing to be communicated with:Preferred method of contact* Direct Mail other than “Reminders” (post office) Phone other than “Reminders” Text Email PhoneEmail We respect your privacy and will not sell, rent or trade any of your personally identifiable information. The above are for communications from our hospital to you, and will not be used for any other reason.Thank you for being a part of our family! We truly care about you and your pet(s) and look forward to communicating with you throughout the year! Release of Media and Information Here at Jefferson Animal Clinic, we like to educate our clients, share interesting cases, facts and tips about caring for your pet(s)! We also love to take pictures and share adorable photos with everyone! No personal or sensitive information is ever used. Do you give Jefferson Animal Clinic permission to release media and information about your pet?* Yes No Signature (or printed name) of Owner or Authorized Agent*EmailThis field is for validation purposes and should be left unchanged.
