Date:

Client Information:

Client Name: *

First

Last

Co-Owner Name: *

First

Last

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone Number *

Phone Type: *

Secondary Phone Number:

Phone Type:

Email Address: *

(We value your personal information. Your email will be used only for notifications from Edmonds-Westgate Veterinary Hospital.)

Additional Authorized Contacts (You authorize us to speak to this person about your pet’s care in the event we cannot reach you.):

Patient Information:

Patient Name: *

Species: *

Cat
Dog

Breed: *

Sex: *

Male
Female

Neutered/Spayed?: *

Yes
No

Color: *

Age/DOB *

What brand of food does your pet eat and how much a day?: *

Is your pet’s food grain free?: *

Yes
No

Previous Health Issues, current medications, or allergies: *

Name/number of previous veterinary clinics (please include ALL clinics that has seen your pet for wellness, illness, and/or emergency or urgent care): *

What social media platforms do you use? *

How did you hear about us? *

We love social media! We would like your consent to share your pets’ image(s) on our social media and website. Your full name and personal information will never be used. *

Yes, please make my pet a star!
No thank you; my pet is shy.

DEPOSIT POLICY: To avoid last minute cancellations or no show appointments that affect how we can provide the best and fastest care to all our patients in need, we do require a deposit for certain types of appointments such as a new client first time consult and surgical procedures. These deposits will be collected at the time of scheduling and will be applied to the invoice at the end of that appointment. Our cancellation/rescheduling policy outlines when a deposit will be forfeited by you.

CANCELLATION POLICY: If you must cancel an appointment, we ask for 24 hours notice. If canceling a surgical appointment, we ask for 48 hours notice. A late cancellation or frequent cancellations/reschedules may result in a fee being applied to your account, a non-refundable deposit needing to be taken for future visits, and/or the forfeiting of a previous deposit for that appointment.

RABIES VACCINATION POLICY: Current proof of vaccination against Rabies is required at Edmonds-Westgate Veterinary Hospital prior to providing service to any animal. These measures are taken to protect the wellbeing of all animals and staff within our hospital.

TREATMENT CONSENT: I hereby authorize the veterinarian to examine, prescribe or treat the above-described pet(s). I assume responsibility for all charges incurred in the care of this animal. I understand that payment is due in full at the time of service. I recognize that financial concerns should be discussed prior to exam and treatment. For your convenience, we accept all major credit cards, CareCredit, and cash.

I confirm that the above information is correct and that I am the owner or authorized agent of the patient(s) listed above.

Client’s Typed Name: *

Signature *

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Client Information:

Patient Information:

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