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 or GTCC Employee? * Yes No Please Select One * Cone Health EmployeeGuilford County Schools EmployeeGTCC 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 * Were you referred to us by a friend, family member, or another client? * Yes No Who may we thank for referring you? * This allows them to receive credit for the referral. 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
