Registration Form Registration Form - English Are you a repeat client? * Yes No Name * Name First First Last Last Spouse's Name Spouse's Name First First Last Last Email * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Home Phone * Cell Phone * Work Phone Nearest Relative Not Living with You * Phone * (Receptionist required to make photocopy of license.) Are You an Active or Former Police Officer/Fire Fighter/Military Personnel? * Yes No Please Select One * Active Police OfficerActive FirefighterActive Military PersonnelFormer Police OfficerFormer FirefighterFormer Military Personnel Are You a Senior Citizen (65 Years or Older)? Yes No Are You a Cone Health Employee or full-time Guilford County Schools Employee? * Yes No Please Select One * Cone Health EmployeeGuilford County Schools Employee Do You Have Pet Insurance? * Yes No If Yes, Do You Have Trupanion? Yes No Name of Regular DVM (Veterinary) Hospital * Please write "No Vet" if this doesn't apply. Reason for Your Pet’s Visit to Happy Tails * How Did You Hear About Happy Tails Veterinary Emergency Clinic? (Please Check All That Apply) * Location/signage in front of clinic Facebook / Instagram Magazine / TV Referral from regular veterinarian Direct mail Referral from a friend Repeat Client Google search / Website Friend's Name * At times we take photos of our patients for educational or uplifting purposes to be used on our social media or website. * Yes, I consent for my pet's photos/ information to be used by Happy Tails Veterinary Emergency Clinic. No, I do not consent for my pet's photos/ information to be used by Happy Tails Veterinary Emergency Clinic. If you are human, leave this field blank. Next
