Name

Spouse's Name

Address (City, State, ZIP)

Home Phone

Cell Phone

Spouse's Cell

Emergency Phone #

Can we e-mail you our newsletter and your pet's health reminders?

Yes   No  

E-Mail Address

Pet's Name

Species

DogCatBirdFerretRabbitHamsterGerbilGuinea PigRatOther

Breed

Sex

MaleFemaleNeutered MaleSpayed Female

Color/Markings

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?