Client Registration and Emergency Authorization Form Client Registration and Emergency Authorization FormThank you for choosing Coast Veterinary Services. We are so happy your here! We are dedicated to providing your pets and horses with high quality compassionate medicine. We look forward to becoming an important part of keeping them happy and healthy. Tell us about you!Owner’s Name:Spouse, if Applicable:Address: Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone Number Home:Cell Phone Number:Other Phone Number:Email: Tell us about your pet or horse!Patients Name:Breed:Year of Birth or age: Sex:MaleFemaleSpayed/ Neutered:YesNoColor:Microchipped:YesNoInsured:YesNoContact Number for Insurance:Previous veterinary health care providers:May we contact them for record requests:YesNoPatients Current Medications:Patients Current Diet:Brief description of patients current living environment:Reason for appointment:Other concerns I have with my pet/horse are:Do you have other pets/horses to register with us? Enter their information here Name:Breed:Age:Sex:MaleFemaleColor:Tell Us About Your LifeOn a scale of 1-10, my home is like a: 1- zen garden, 10- wild circusOn a scale of 1-10, my animal care is: 1- broad strokes, they get fed, 10- fine toothed comb. I keep a journal about all their activities.On a scale of 1-10 I am interested in integrated medicine such as acupuncture, herbal supplements and physical therapy 1-no way 10- prefer it over convential medicineMy preferred method of communication: Text Email Phone How did you hear about us? Yelp Sign Referral Facebook Instagram Google Search Other I understand that payament is due in full at the time of service. We will gladly prepare a written treatment plan before services are rendered upon request. I consent to sharing my pet on social media and marketing materials:YesNoIn the case of a medical emergency, if I cannot be reached, I herby give the below person(s) permission to authorize Coast Veterinary to provide any medical treatment deemed necessary for my horses or pets and permission for the doctor to treat to their best clinical judgment. I will be responsible for charges incurred in that treatment.Name:Phone Number:Name:Phone Number:Signature:Date: Thanks for entrusting us with your four legged friends care. We consider it an honor and strive to provide the highest quality care available. Be sure to "like" us on Facebook or follow us on Instagram!