Personal Information

Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone *

Work Phone

Emergency Contact

Name *

First

Last

Phone Number

How did you find out about us?

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Tell us who recommended you to us

Pet Information

First Pet's Name *

Species *

Breed *

Color & Markings *

Microchip Number *

Date of Birth/Age *

Sex *

Male
Female
Unknown

Spayed/Neutered *

Yes
No
N.A.

Do you have a second pet? *

Yes
No

Second Pet's Name *

Species *

Breed *

Color & Markings *

Microchip Number *

Date of Birth/Age *

Sex *

Male
Female
Unknown

Spayed/Neutered *

Yes
No
N.A.

Do you have a third pet? *

Yes
No

Third Pet's Name *

Species *

Breed *

Color & Markings *

Microchip Number *

Date of Birth/Age *

Sex *

Male
Female
Unknown

Spayed/Neutered *

Yes
No
N.A.

Do you have a fourth pet? *

Yes
No

Fourth Pet's Name *

Species *

Breed *

Color & Markings *

Microchip Number *

Date of Birth/Age *

Sex *

Male
Female
Unknown

Spayed/Neutered *

Yes
No
N.A.

Do you have a fifth pet? *

Yes
No

Fifth Pet's Name *

Species *

Breed *

Color & Markings *

Microchip Number *

Date of Birth/Age *

Sex *

Male
Female
Unknown

Spayed/Neutered *

Yes
No
N.A.

Terms Of Agreement

Checkboxes *

Yes, I am at least 18 years or older.

Checkboxes (copy) *

Yes, I’d like to receive coupons, promotion specials, appointment, and vaccine reminders via email.

Checkboxes (copy) (copy) *

I authorize South Shores Animal Hospital to take pictures of my pet and upload them into my pet’s medical record and online.

Payment Policy *

We gladly accept Mastercard, Visa, Amex, Discover, cash, checks, and debit. All checks must be in state. Thankyou. Payment is due in full at time of service; we do not allow payment arrangements. A deposit of 75% is required on all hospitalized cases.

Hospital Agreement *

I, the undersigned owner or authorized agent of the admitted patient, hereby authorize the admitting veterinarian to administer such treatment, and additional procedures as are considered therapeutically and/or diagnostically necessary. I,also consent to the administration of such anesthetics as are necessary. I further understand that no guarantee of successful treatment is made and that risks and probabilities of complications exist in any surgical or medical treatment. I understand that charges are made for services rendered and that payment for such charges are due at the time they are rendered, or prior to discharge of the pet patient animal from the hospital. Any animal not picked up within the time required by Statute No.NAC637.051 of the Nevada State board of Medical Examiners shall be deemed abandoned by the owner and will be disposed of according to said statute. Furthermore, this action will not, however, relieve me from paying all charges rendered, all legal and/or court costs and collection agency fees incurred in connection with the collection of services.

Signature Of Owner *

Clear Signature

Date *

Welcome New Clients!
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New Client Form

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Welcome New Clients! Book today and get $30 off your first visit with an exam!

New Client Form

New Client Form

Personal Information

Emergency Contact

How did you find out about us?

Pet Information

Terms Of Agreement

Welcome New Clients!
Book today and get $30 off your first visit with an exam!