Sahara Pines Animal Hospital

6533 West Sahara Avenue
Las Vegas, NV 89146-2909

(702)876-7580

www.saharapinesah.com

New Client Registration

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for giving us the opportunity to care for your pet. We'll be happy to answer any question you have about your pet's health. To ensure the best care possible, please take the time to fill in this form completely.

New Client

Name *(required)*

First Name (required)	Last Name (required)

Address (required)
Street Address (required)

City (required) ,	State / Province (required)	Zip / Postal Code (required)

Primary Phone (required)
Phone Type	Phone Number (required)

Secondary Phone
Phone Type	Phone Number

E-Mail Address :

Spouse/Other Name

First Name	Last Name

Spouse/Other Phone
Phone Type	Phone Number

Pet's Name (required)

Age: Years, Months

Type of Pet (required) :

Breed:

Sex: (required)

Male
Female

Neutered/Spayed

Neutered
Spayed

Are your pet's vaccines current?

Yes
No

Do you have pet's medical records?

Yes
No

Medical records at another veterinary Practice?

Yes
No

Name of Former Veterinary Practice

May we request a transfer of records?

Yes
No

Would you like us to call you for your appointment

Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

How did you hear about our hospital?
Pet Store
Yellow Pages
Drive-by
Live close
Walk-in
Previous client

If referred by a client, who may we thank?

Check the reCAPTCHA to ensure you are not a robot:

Mon-Fri	7 am	6 pm
Sat	8 am	5 pm
Sun	Closed