Bellevue Animal Hospital New Client Information

Client ID
New Client Information
Owner*
Spouse/Additional Owner*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Cell Phone*
Additional Authorized Contact Name and Number*
You authorize us to speak to this person about your pet’s care in the event we cannot reach you.
Email*
example@example.com
Drivers’ License Number
We value your personal information. Your email will only be used for notifications from Bellevue Animal Hospital.

Please complete if you plan on writing checks.
What social media platforms do you use?

FacebookTwitterInstagramLinkedInGoogle
How did you hear about us?*

Family / FriendWebsiteGoogle / Online SearchDriving/Walking by
If you were referred by a client, please tell us who so we can say thank you.
NEW PATIENT INFORMATION
Pet’s Name*
Breed*
DogCat
Sex:*

MaleFemaleNeuteredSpayed
Birthday/Age*
Color*
Previous Health Issues*
Pet’s Name
Breed
DogCat
Sex:

MaleFemaleNeuteredSpayed
Birthday/Age
Color
Previous Health Issues
Name and number of your pets’ previous veterinarian?*
We love social media! We would like your consent to share your pets’ image 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
If you must cancel an appointment, we ask for 24 hours’ notice. If cancelling a surgical appointment, we ask for 48 hours’ notice. A late cancellation or frequent cancellations may result in a fee being applied to your account. Current vaccinations are required by Bellevue Animal Hospital before we may admit any animal for any reason. These measures are taken to protect the well-being of all animals within our hospital.

Treatment Consent: I hereby authorize the veterinarian to examine, prescribe for 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 always due infull at the time of service. I recognize that financial concerns should be discussed prior to exam and treatment. For your convenience we accept Visa, Mastercard, American Express, cash and checks with proper identification. Please stop at the reception desk to review and pay for services. I confirm that the above information is correct and that I am the owner or authorized agent of the patient (s) listed above.
Signature*

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Date

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Date
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New Client Information

NEW PATIENT INFORMATION