Address (City, State, ZIP)
Emergency Phone #
Can we e-mail you our newsletter and your pet's health reminders?
MaleFemaleNeutered MaleSpayed Female
Date of Birth
Where did you acquire your pet?
Humane ShelterPrivate BreederPet StoreFoundOther
Why did you choose Bartels Busack Pet Clinic?
Yellow Page Listing Hospital Listing Reputation Groomer Location Website Breeder Recommendation Knowledge of a Specific Doctor
If recommened by another person, please let us know who?