testing formClient 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 SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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: MM slash DD slash YYYY Sex: Male Female Spayed/ 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: Male Female Color: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: Yes No In 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: MM slash DD slash YYYY 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!
