Client Registration

Please fill out completely. It may be necessary at some time to contact you concerning needed treatment or the progress of your pet, and this information can save us valuable time. Some of the information is also necessary in order to accept checks for payments. Thank you.

You may also download and print the form. 


Avian Form Avian Form

AVIAN & MAMMALS

  • Yes
  • No
  • Other
  • Yes
  • No
  • Other
  • Google
  • Facebook
  • Youtube
  • Friend
  • Another Vet
  • Other

PAYMENT FOR SERVICES DUE WHEN RENDERED

  • Check
  • Cash
  • Mastercard
  • Visa
  • Discover

Identification necessary in order to accept checks and credit cards. Nearest relative not living with you:

---------------PATIENT INFORMATION-----------------

  • Male
  • Female
  • Unknown
  • Captive bred
  • Hand fed
  • Wild Caught
  • Companion
  • Breeder
  • Unknown
  • Pellets
  • Seed
  • Fruit & veggies
  • Table food
  • Handfeeding
  • Other

Recent Changes in:

  • Yes
  • No

I grant Exotic bird hospital and any and all its subsidiaries full permission to use any and all images taken of me or my pets for the sole use of education, advertisement and promotion. This includes but is not limited to Facebook, Twitter, Youtube videos and other Social media sites, websites blogs and website display. I certify that I am 18 years of age or older.

8820 Old kings rd South, Jacksonville Fl 32257 PH: 9042560043