WESTMINSTER VETERINARY HOSPITAL New Client Form

Welcome to Westminster Veterinary Hospital!

Please fill this out this form within 24 hours or your appointment will be canceled. Thanks for letting us take care of your pet! . All pets must arrive on leashes or in carriers.
Today's Date

MonthDayYear
Date
Appointment Date*

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*

Area CodePhone Number
Phone Type
Secondary Phone

Area CodePhone Number
Phone Type
Email *
example@example.com
Co-owner/Spouse's Name

First NameLast Name
Co-owner/Spouse's Phone Number

Area CodePhone Number
Phone Type
How did you learn about our practice?*
If referred by a friend or family member, who may we thank?
Pet's Name*
Species*

DogCat
Breed*
Color*
Gender*

MaleMale NeuteredFemaleFemale Spayed
Birth Date

MonthDayYear
Date
If birth date is unknown, approximate age
Pet's Name #2
Species

CatDog
Breed
Color
Gender

MaleMale NeuteredFemaleFemale Spayed
Birth date

MonthDayYear
Date
If birth date is unknown, approximate age
Do you have pet insurance?*

YesNo
If yes, name of insurance company?
Please provide the name and phone number or your pet's previous veterinarian so that we may call to collect medical history.*
Please fax records to 410.848.4959 or email to clientcare@westminsterveterinaryhospital.com. Thank you!
Do you grant Westminster Veterinary Hospital permission to post photos of your pet onto their social media forums and/or website?*

YesNo
MISSED/LATE APPOINTMENT POLICY:

Our goal is to provide quality individualized medical care in a timely manner. No-shows, late shows and cancellations inconvenience owners seeking timely medical attention to their pets. We would like to inform you of our policy regarding missed appointments.

CANCELLATION OF AN APPOINTMENT:

In order to be respectful of the medical needs of other patients, please be courteous and call our office promptly if you are unable to keep an appointment. This time will be reallocated to another pet in need of treatment. Appointments are in high demand and your early cancellation will allow another patient access to timely medical care.

LATE APPOINTMENTS:

If you are running more than 5 minutes late, contact the office at 410.848.336. Late appointments may limit the doctor's ability to address more than one concern at your pet's appointment. If you arrive 15 minutes late or more you may be required to reschedule your pet's appointment.

If you have 3 or more no-shows you will be required to pay a deposit of the appropriate fee at the time of scheduling your pet's appointment.
Authorization

I hereby authorize the veterinarian to examine, prescribe for or treat the above described pet. I assume all responsibility for all charges incurred for the care of the animal. I understand that all professional fees are due at the time services are rendered. I also understand and agree to the Missed Appointment Policy.
Signature of client responsible for pet:

Clear
Should be Empty:

Welcome to Westminster Veterinary Hospital!