testing form Client Registration and Emergency Authorization 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 NumberOther Phone NumberEmail Tell us about your pet or horse!Patients NameBreedYear of Birth or age SexMaleFemaleSpayed/ NeuteredYesNoColorMicrochipped:YesNoInsuredYesNoContact Number for InsurancePrevious veterinarey heallthcare providersMay we contact them for record requestsYesNoPatientsCurrentMedicationsPatients Current Diet:Brief description of patients current living environmentReason for appointmentOther concerns I have with my pet/horse are:Do you have other pets/horses to register with us? Enter their information hereNameBreedAgeSexMaleFemaleColorTell us about your life!On 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 commincation:TextEmail PhoneHow did you hear about us? Yelp, Sign, Referral, facebook, Instagram, Google search, otherI 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 materialsYesNoIn 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.NamePhone NumberNamePhone NumberSignatureDate 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!