PetCare+ Registration

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0 height="100%"><tr> <td valign="top" width=210 BGCOLOR="#CC9966" TEXT="#080000" bgproperties="fixed" background="039e5e32dkesoe.png"> <bR> <bR> <bR> <bR> <div> <A HREF="id2.htm" TARGET="_top" TITLE="Staff/Facilities"><U><B>Staff/Facilities</B></U></A></div> <div> <A HREF="id54.htm" TARGET="_top" TITLE="News and Information"><U><B>News and Information</B></U></A></div> <div> <A HREF="id4.htm" TARGET="_top" TITLE="Veterinary Services"><U><B>Veterinary Services</B></U></A></div> <div> <A HREF="id91.htm" TARGET="_top" TITLE="Ancillary Services"><U><B>Ancillary Services</B></U></A></div> <div> <A HREF="id3.htm" TARGET="_top" TITLE="Feedback"><U><B>Feedback</B></U></A></div> <div> <A HREF="id88.htm" TARGET="_top" TITLE="Links"><U><B>Links</B></U></A></div> <div> <A HREF="index.htm" TARGET="_top" TITLE="The Animal Clinic of Los Alamos, P.C."><U><B>Home</B></U></A><B> </B></div> <bR> <bR> <div> <B> </B><A HREF="id21.htm" TARGET="_top" TITLE="PetCare Philosophy"><U><B><IMG SRC="07870250.jpg" border=0 width="112" height="37" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A></div> </td> <td valign="top" BGCOLOR="#FFCC99" TEXT="#080000"> <div> <FONT SIZE="6" COLOR="#990000" FACE="Arial" ><B>The Animal Clinic of Los Alamos, P.C.</B></FONT><B> </B><FONT SIZE="3" COLOR="#CC0000" FACE="Times New Roman" ><A HREF="index.htm" TARGET="_top" TITLE="The Animal Clinic of Los Alamos, P.C."><U><B>home</B></U></A></FONT><FONT SIZE="3" COLOR="#663300" FACE="Times New Roman" ><B> </B></FONT><B>  </B></div> <bR> <div> <B>  |</B></div> <div> <B>PetCare+ Registration</B></div> <DIV ALIGN="LEFT"></DIV> <div> <B><IMG SRC="074d29a0.jpg" border=0 width="466" height="154" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B>To enroll your pet in the pet care plus program please copy the form below </B><B>or download   <a href="HTMLobj-127/PC__Reg.pdf"><u>PC__Reg.pdf</u> </a>  </B><B>, and fill out the information then return to our hospital at:</B></div> <DIV ALIGN="LEFT"></DIV> <div> <B>ACLA</B></div> <div> <B>Pet Care Plus</B></div> <div> <B>127 B Eastgate Drive</B></div> <div> <B>Los Alamos, NM  87544</B></div> <bR> <div> <B>CLIENT INFORMATION</B></div> <DIV ALIGN="LEFT"></DIV> <div> <B> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="646" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="636"><div> <B>Owner's Name:                              Spouse's Name:</B></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="636"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="636" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="636"><div> <B>Address:</B></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="636"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="636" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="636"><div> <B>City:                     State:               Zip Code:          </B></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="636"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="636" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="636"><div> <B>e-Mail :</B></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="636"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="636" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="636"><div> <B>Phone number -Home:                         Work:</B></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="636"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="636" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="636"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="636" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></B></div> <bR> <bR> <div> <B>                                                            PATIENT INFORMATION</B></div> <DIV ALIGN="LEFT"></DIV> <div> <B> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="612" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP ROWSPAN=2 HEIGHT= 39 WIDTH="107"><div> <I><B>Pet Name</B></I></div> <bR> <bR> </tD> <tD VALIGN=TOP ROWSPAN=2><NOBR><div> <I><B>K-9 or</B></I></div> <div> <I><B>Feline</B></I></div> </NOBR></tD> <tD VALIGN=TOP ROWSPAN=2 WIDTH="94"><div> <I><B>Breed</B></I></div> </tD> <tD VALIGN=TOP ROWSPAN=2><NOBR><div> <I><B>Color</B></I></div> </NOBR></tD> <tD VALIGN=TOP ROWSPAN=2 WIDTH="52"><div> <I><B>Sex </B></I></div> <div> <I><B>F or M</B></I></div> </tD> <tD VALIGN=TOP ROWSPAN=2><NOBR><div> <I><B>Spayed</B></I></div> <div> <I><B>/Neutered?</B></I></div> </NOBR></tD> <tD VALIGN=TOP WIDTH="58"><div> <I><B>Date of Birth</B></I></div> </tD> <tD VALIGN=TOP WIDTH="76"><div> <I><B>MONTH OF EXAM/VACC</B></I></div> </tD> </tR> <tR> <tD VALIGN=TOP WIDTH="58"><div> <B>   /    /</B></div> </tD> <tD VALIGN=TOP WIDTH="76"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="76" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=8 BGCOLOR=#FFFFFF HEIGHT= 20 WIDTH="588"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="588" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></B></div> <div> <B>  PATIENT INFORMATION</B></div> <DIV ALIGN="LEFT"></DIV> <div> <B> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="612" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP ROWSPAN=2 HEIGHT= 39 WIDTH="107"><div> <I><B>Pet Name</B></I></div> <bR> <bR> </tD> <tD VALIGN=TOP ROWSPAN=2><NOBR><div> <I><B>K-9 or</B></I></div> <div> <I><B>Feline</B></I></div> </NOBR></tD> <tD VALIGN=TOP ROWSPAN=2 WIDTH="94"><div> <I><B>Breed</B></I></div> </tD> <tD VALIGN=TOP ROWSPAN=2><NOBR><div> <I><B>Color</B></I></div> </NOBR></tD> <tD VALIGN=TOP ROWSPAN=2 WIDTH="52"><div> <I><B>Sex </B></I></div> <div> <I><B>F or M</B></I></div> </tD> <tD VALIGN=TOP ROWSPAN=2><NOBR><div> <I><B>Spayed</B></I></div> <div> <I><B>/Neutered?</B></I></div> </NOBR></tD> <tD VALIGN=TOP WIDTH="58"><div> <I><B>Date of Birth</B></I></div> </tD> <tD VALIGN=TOP WIDTH="76"><div> <I><B>MONTH  OF EXAM/VACC</B></I></div> </tD> </tR> <tR> <tD VALIGN=TOP WIDTH="58"><div> <B>   /    /</B></div> </tD> <tD VALIGN=TOP WIDTH="76"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="76" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=8 BGCOLOR=#FFFFFF HEIGHT= 20 WIDTH="588"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="588" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></B></div> <div> <B>                                                            PATIENT INFORMATION</B></div> <DIV ALIGN="LEFT"></DIV> <div> <B> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="612" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP ROWSPAN=2 HEIGHT= 39 WIDTH="107"><div> <I><B>Pet Name</B></I></div> <bR> <bR> </tD> <tD VALIGN=TOP ROWSPAN=2><NOBR><div> <I><B>K-9 or</B></I></div> <div> <I><B>Feline</B></I></div> </NOBR></tD> <tD VALIGN=TOP ROWSPAN=2 WIDTH="94"><div> <I><B>Breed</B></I></div> </tD> <tD VALIGN=TOP ROWSPAN=2><NOBR><div> <I><B>Color</B></I></div> </NOBR></tD> <tD VALIGN=TOP ROWSPAN=2 WIDTH="52"><div> <I><B>Sex </B></I></div> <div> <I><B>F or M</B></I></div> </tD> <tD VALIGN=TOP ROWSPAN=2><NOBR><div> <I><B>Spayed</B></I></div> <div> <I><B>/Neutered?</B></I></div> </NOBR></tD> <tD VALIGN=TOP WIDTH="58"><div> <I><B>Date of Birth</B></I></div> </tD> <tD VALIGN=TOP WIDTH="76"><div> <I><B>MONTH OF EXAM/VACC</B></I></div> </tD> </tR> <tR> <tD VALIGN=TOP WIDTH="58"><div> <B>   /    /</B></div> </tD> <tD VALIGN=TOP WIDTH="76"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="76" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=8 BGCOLOR=#FFFFFF HEIGHT= 20 WIDTH="588"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="588" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></B></div> <div> <B>    PATIENT INFORMATION</B></div> <DIV ALIGN="LEFT"></DIV> <div> <B> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="612" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP ROWSPAN=2 HEIGHT= 39 WIDTH="107"><div> <I><B>Pet Name</B></I></div> <bR> <bR> </tD> <tD VALIGN=TOP ROWSPAN=2><NOBR><div> <I><B>K-9 or</B></I></div> <div> <I><B>Feline</B></I></div> </NOBR></tD> <tD VALIGN=TOP ROWSPAN=2 WIDTH="94"><div> <I><B>Breed</B></I></div> </tD> <tD VALIGN=TOP ROWSPAN=2><NOBR><div> <I><B>Color</B></I></div> </NOBR></tD> <tD VALIGN=TOP ROWSPAN=2 WIDTH="52"><div> <I><B>Sex </B></I></div> <div> <I><B>F or M</B></I></div> </tD> <tD VALIGN=TOP ROWSPAN=2><NOBR><div> <I><B>Spayed</B></I></div> <div> <I><B>/Neutered?</B></I></div> </NOBR></tD> <tD VALIGN=TOP WIDTH="58"><div> <I><B>Date of Birth</B></I></div> </tD> <tD VALIGN=TOP WIDTH="76"><div> <I><B>MONTH  OF EXAM/VACC</B></I></div> </tD> </tR> <tR> <tD VALIGN=TOP WIDTH="58"><div> <B>   /    /</B></div> </tD> <tD VALIGN=TOP WIDTH="76"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="76" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></B></div> <div> <B> </B></div> <div> <B>Please mark below for your preferred method of reminders</B></div> <bR> <div> <B>Telephone      Mail      E-Mail</B></div> <bR> <bR> <div> <B>Postal Address:  127-B Eastgate Dr., Los Alamos, NM 87544     </B></div> <div> <B>   Phone: 505.662.6622       Fax: 505.662.3552</B></div> <div> <FONT SIZE="2" COLOR="#663300" FACE="Times New Roman" ><B>e-Mail: </B></FONT><B> </B><A HREF="mailto:aclapets@newmexico.com" TARGET="_top" TITLE="mailto:aclapets@newmexico.com"><U><B>aclapets@newmexico.com</B></U></A></div> <div> <B>  <script type="text/javascript" language="javascript"> var sc_project=889920; var sc_invisible=1; var sc_partition=7; var sc_security="fc09d6ea"; </script> <script type="text/javascript" language="javascript" src="http://www.statcounter.com/counter/counter.js"></script><noscript><a href="http://www.statcounter.com/" target="_blank"><img src="http://c8.statcounter.com/counter.php?sc_project=889920&java=0&security=fc09d6ea&invisible=1" alt="counter" border="0"></a> </noscript>   </B></div> <div> Site and all contents property of ACLA</div> <div> Copyright 1999-2007 all rights reserved.</div> <div> Site maintained by WyrmWyrks</div> <bR> <bR> </td> </tr></table></body>