Small Animal Emergency Hospital of Westfield

Small Animal Emergency Hospital of Westfield

New Client Registration
Owners Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / 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 MaleSpayed FemaleUnaltered MaleUnaltered Female
Previous Medical History*
Reason for todays visit*
Form a payment*

Credit CardDebit CardCare CreditScratch 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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Small Animal Emergency Hospital of Westfield

Pets Information