Microchip Registration Form

A microchip implant is an identifying integrated circuit placed under the skin of a pet. It emits a radio frequency signal that transmits data to a special handheld device. After verifying that your pet does not already have a chip, we will record the microchip's unique identification code and inject the chip using a sterile syringe, just under the skin between the shoulder blades. If you are planning on having your pet microchipped, please complete the form. The registration will be finalized at the time of the microchip implant.

Email*
Enter Email Confirm Email
Owner Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Residence Phone
Cell Phone
Business Phone
Pet Information
Call Name*
Registered Name
Species*
Breed*
Color / Markings*
Tattoo
Date of Birth*
Date Format: MM slash DD slash YYYY
Registration Number & Association
Sex*
Adoption Number
License Number
Medical Information
Medical Illnesses / Allergies
Medications
Rabies Vaccination Date
In the event you don't have the Rabies date, we will review our records and put in the date and Rabies Tag # for you.
Date Format: MM slash DD slash YYYY
Rabies Tag Number
Alternate Contact or Breeder
Alternate Name
First Last
Telephone
Breeder Name
First Last
Telephone

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Microchip Registration Form

Owner Information

Pet Information

Medical Information

Alternate Contact or Breeder

CLEARWATER ANIMAL HOSPITAL

LASALLE ANIMAL HOSPITAL

CVO ACCREDITED