New Canine Registration Form

Name *

First

Last

Spouse's Name

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Home Phone *

Cell Phone

I consent to receive SMS text messages from Medway Animal Hospital. Msg & data rates may apply. Reply STOP to opt-out. *

Yes
No

Work Phone

Employer

Emergency Contact Name

Emergency Contact Phone Number

Pet's Name *

Pet's Birth Date *

Pet's Breed *

Pet's Color *

Pet Sex *

Male - Neutered
Male - Not Neutered
Female - Spayed
Female - Not Spayed

Where did your purchase/adopt your pet? *

How long have you owned your pet? *

Multiple pet household? *

Yes
No

Is your dog vaccinated against:

Canine Distemper
Rabies
Lyme
Bordetella (Kennel Cough)

If so, when?

If your dog has been tested for heartworm, please provide results:

Positive
Negative

Date:

If your dog has been tested for Lyme, please provide the results:

Positive
Negative

Date:

Date of most recent worming:

Has your dog been hit by a car?

Yes
No

Does your cat have any other medical problems or is on any medication at this time? (check is applicable)

If Other, please explain:

What brand/type of dog food do you feed your dog?

How many times per day do you feed your dog?

Once
Twice
Free Choice

Is your dog given nutritional supplements?

Yes
No

Does your dog eat foreign objects?

Yes
No

Is so, what?

What is your dog’s activity level?

Highly active
Active
Moderate
Couch Potato

How did you hear about our hospital?

Who can we thank for the recommendation?

Would you like to receive email reminders or health updates?

Yes
No

Complete your dogs’s registration form online, at your convenience.