Thank you for considering our hospital as your pet’s provider of veterinary services. Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process.Owner's InformationName(Required) First Last Address(Required) 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 Primary Phone(Required)Secondary PhoneMobile PhoneEmail(Required) Co-owner's Name & Contact #Name First Last PhoneHow did you find out about our practice?(Required)Please SelectClinic Location/SignPersonal ReferralGoogle SearchFacebook/InstagramYelpMagazine / Print AdOtherIf Other, please specifyIf Personal Referral, is there someone we can thank for this referral?Please use this area to give us any other relevant information about yourself or your familyOn occasion we may take a photo of your pet for our website, educational or social media use, please select below for your consent.(Required) Yes, I give Hale Ola Pet Hospital authorization to take photos of my pet No, I do not give Hale Ola Pet Hospital authorization to take photos of my petPet InformationPet's Name(Required)Species(Required)Please SelectDogCatBreed (if known)Sex(Required)Please SelectNeutered MaleSpayed FemaleMaleFemaleUnknownColorDate of Birth or Age (if known)Special Identification (tattoo, microchip, etc.)Previous Veterinary Practice (if any)Previous Veterinarian (if any)Date of last vaccines (if known)What vaccines were given at this timeIs your pet on any medication or supplement?Please SelectYesNoDoes your pet have allergies or drug reactions?Please SelectYesNoIf Yes, please list the medication or supplementIf Yes, please list the allergies and reactionsWhat food does your pet eat?Are there any current or past medical conditions of which we should be aware?Please SelectYesNoIf Yes, please comment on the condition(s) and indicate if they are current or past conditionsPlease use the following box to give us any other relevant information about your petCAPTCHAΔ
