New Pet Form Welcome to our Hospital! Our team of experts offer family centered care to help enrich you and your pets lives for the better each and every day. We appreciate you selecting us for your Veterinary Health Care needs! Pet's Name* Breed* Microchip # Color* Date of Birth* MM slash DD slash YYYY Sex* Male Female Has your pet been vaccinated within the last year?* Yes No If so, please specify Veterinarian’s name/Hospital* Rabies given?* Yes No If so, please specify Veterinarian’s name/Hospital* Owner InformationOwner Name* First Last Address* Street Address Address Line 2 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*Email* Ask us about setting up your Pet Portal!Work PhoneEmployer Name First Last Person to Contact if You Cannot Be Reached* Secondary contact phone*How were you referred to this hospital?* Google Web Site Yellow Pages Sign Friend/Family Other Please specify* From time to time we update the pet photos on our Facebook and Web Site. Please acknowledge If you would like to voluntarily participate in allowing Family VetCare to publish photographs of your pet(s) on our printed publications, and social media by selecting one of the following:* No I do not wish to participate Yes I authorize Family VetCare to publish photographs taken of my pet(s) for use in FamilyVetCare’s printed publications and social media. I acknowledge that since my participation in publications and Social Media produced by Family VetCare is voluntary, I will receive no financial compensation. I further agree that my participation in any publications and social media by Family VetCare confers upon me no rights of ownership whatsoever. I release Family VetCare, its contractors and its employees from liability for any claims by me or any third party in connection with my participation. Signature (type your name)* Date* MM slash DD slash YYYY I, the undersigned, accept responsibility for all fees** incurred in the care of any and all of my animals at the time services are rendered, and that a deposit may be required for some treatments and services. I also understand that Family VetCare of Chandler accepts: Cash, Visa, MasterCard, American Express, Discover, and Care Credit.* I accept responsibility for all fees ** All fees incurred by accounts turned over to a collection agency will be the responsibility of the Pet Owner.Choose Hospital Location*Chandler HospitalMesa HospitalPhoenix/ Ahwatukee HospitalDate* MM slash DD slash YYYY Signature of pet owner (type your name)*CAPTCHA Δ