REGISTRATION FORM Ashleigh Veterinary Centre, 221 Upper Chorlton Road, M16 ODE.

Please complete all sections using BLOCK CAPITALS.

OWNER DETAILS:

TITLE: Miss/Mrs/Ms/Mr FIRST NAME:................................... SURNAME...........................................

ADDRESS:......................................................... TEL NUMBER HOME.......................................................

.......................................................... TEL NUMBER WORK......................................................

........................................................... TEL NUMBER MOBILE..................................................

........................................................... POST CODE...................................

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PET DETAILS:

NAME...................................... BREED/TYPE...................................... DATE OF BIRTH/AGE.......................

SEX................................ COLOUR.......................................... NEUTERED YESq NOq

IS THIS PET: IDENTICHIPPED YESq NOq

COVERED BY PET INSURANCE YESq NOq company name................................................

VACCINATED YESq NOq date of last vaccination......................................

DO YOU/HAVE YOU HAD ANY OTHER PETS REGISTERED AT OUR PRACTICE YESq NOq

NAME OF PET(S).............................................................................................................................................

HOW DID YOU HEAR ABOUT THIS PRACTICE:

CLIENT RECOMMENDATIONq YELLOW PAGESq OTHERq (Please specify)..............................................

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PAYMENT DETAILS:

PLEASE INDICATE YOUR PREFERRED METHOD OF PAYMENT:

Cashq Credit cardq Debit cardq Switchq personal cheque + Guarantee cardq

Please note that fees are payable at the time of treatment. We do not operate credit accounts. You will be liable for any interest, court costs, or recovery fee incurred to enforce collection of any oustanding balance on your account, should this be necessary.

Please register me at Ashleigh Veterinary Centre. IN SIGNING THIS FORM I AGREE TO THE FOLLOWING:

* I agree to pay in full all fees incurred in the treatment of my animals

* I understand that such fees are payable at the time of treatment

* I will be liable for any charges incurred to enforce the collection of any outstanding balance on my account

Signature of owner................................................. Date..........................................

(or authorised agent)

......................................................................................................................................................................................

For official use only nurse initials.................