Small Animal Emergency Hospital of Westfield

Small Animal Emergency Hospital of Westfield

New Client Registration
Owners Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Phone Number *
Please enter a valid phone number.
Alternate Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Primary Care Veterinarian / Clinic *
Primary Care Veterinarian / Clinic Phone Number *
Please enter a valid phone number.
Primary Care Veterinarian / Clinic Email *
example@example.com
Pets Information
Pets Name *
Species *
Breed *
Color *
Date of birth or approximate age *
Gender *

Neutered Male Spayed Female Unaltered Male Unaltered Female
Previous Medical History *
Reason for todays visit *
Form a payment *

Credit Card Debit Card Care Credit Scratch Pay
I hereby authorize Small Animal Emergency Hospital of Westfield to proceed with the recommended diagnostics, treatment and care for my pet.

I authorize the attending Veterinarian and team members to handle and treat my pet as necessary to ensure safety for all during the evaluation.

I further understand that an estimate may be provided for treatment and care, but verbal consent can also be obtained.

I understand and agree that I am financially responsible for all treatment cost and
that payment is to be made at the time that services is rendered.

Should my payment method fail and collection efforts become necessary, I will be held responsible for costs of collection and / or attorney fees.
By signing below I acknowledge I understand and agree to all above conditions. *

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Date *

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Small Animal Emergency Hospital of Westfield

Pets Information