Download & Print FormName* First Last Spouse/Other Caregiver Name First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell #*Home #Work #Spouse Cell #Spouse Home #Spouse Work #Preferred number to contact* Cell Home WorkSpouse preferred number to contact Cell Home WorkOccupation*Employer*OK to call at work?* Yes No Emergency OnlyEmail Address (This is so you can receive copies of your pet’s lab work, report cards, reminders, and occasional informational emails.)* Spouse Email Address Pet's Name*Breed*Color*Sex* Male Female Spayed NeuteredBirthday or Approximate Age*How long owned?*Does your pet take any medications?Where obtained?* Pet Store Shelter Breeder Friend/Neighbor Date of last veterinary visit*Name/Phone of last Veterinarian*I authorize Bear Valley Veterinary Care Center to request previous medical care records from any/all previous providers. (initial)*Reason for leaving last veterinarian?*How did you hear about us? Google Search Facebook Event Sign/Drive by Referral From Family/FriendIf referral, who may we thank?Bear Valley Veterinary Care Center is proud to be accredited by the American Animal Hospital Association (AAHA) for more than 25 years. For more information about our accreditation go to www.healthypet.com. Have you heard of AAHA?* Yes Yes, and it plays a role in my choice of Veterinarian NoI authorize Bear Valley Veterinary Care Center to use photos of my pet on Facebook or other social media sites. (initial)*ALL FEES ARE DUE AT THE TIME THE SERVICES ARE RENDERED. Please review and sign financial policy. I authorize treatment of my pet by the staff and doctors of Bear Valley Veterinary Clinic and confirm that I am at least 18 years of age. (Agree by typing your name below).*Drivers License Number*SignatureReset signature Signature locked. Reset to sign again Δ
