New Client Form

WE KNOW YOUR PET’S HEATH IS IMPORTANT AND WE THANK YOU FOR TRUSTING US TO CARE FOR THEM. TO HELP US PROVIDE THE BEST CARE POSSIBLE, PLEASE TAKE A FEW MOMENTS TO FILL OUT THIS FORM COMPLETELY.

THANK YOU!
Client Information
Name*

First NameLast Name
PREFERRED PRONOUN
PARTNER / SPOUSE / CO-OWNER
PREFERRED PRONOUN
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PRIMARY EMAIL ADDRESS*
example@example.com
CELL PHONE #*
PARTNER / SPOUSE / CO-OWNER CELL PHONE
WORK PHONE
PARTNER / SPOUSE / CO-OWNER WORK PHONE
ADDITIONAL PHONE
WHAT IS YOUR PREFERRED CONTACT NUMBER?*

Cell #Partner /Spouse / Co-Owner Cell #Work #Partner / Spouse / Co-Owner Work #Additional Phone #
HOW DO YOU PREFER TO BE CONTACTED?*

Phone CallText MessageEmail
HOW DID YOU LEARN ABOUT OUR CLINIC?
I give Issaquah Veterinary Hospital permission to use my pets photos for their online content (Optional)

YesNo
Patient Information
NAME OF PET*
TYPE OF PET*

DOGCAT
SEX*

MALE INTACTMALE NEUTEREDFEMALE INTACTFEMALE SPAYED
BREED*
COLOR*
BIRTHDATE OR AGE*
PREVIOUS VET CLINIC*
Previous Records

Please attach any records, invoices or pictures of our pet's veterinary history here.
Cancelof
Do you have another pet?*

YesNo
NAME OF PET
TYPE OF PET

DOGCAT
SEX

MALE INTACTMALE NEUTEREDFEMALE INTACTFEMALE SPAYED
BREED
COLOR
BIRTHDATE OR AGE
PREVIOUS VET CLINIC
Previous Records

Please attach any records, invoices or pictures of our pet's veterinary history here.
Cancelof
Does your pet have insurance?*

YesNo
Who is your pet's insurance provider?
Would you like to add another pet?

YesNo
NAME OF PET
TYPE OF PET

DOGCAT
SEX

MALE INTACTMALE NEUTEREDFEMALE INTACTFEMALE SPAYED
BREED
COLOR
BIRTHDATE OR AGE
PREVIOUS VET CLINIC
Previous Records

Please attach any records, invoices or pictures of our pet's veterinary history here.
Cancelof
Does your pet have insurance?*

YesNo
Who is your pet's insurance provider?
Do you need to schedule an appointment?*

Yes, please let me know when you have an appointment available.No, I already have an appointment
After completing this form a staff member will contact you to schedule an appointment. Please note that a $25 deposit is required to schedule your first appointment and will be applied to the cost of your visit. This deposit is refundable as long as you give us 24 hours notice to cancel otherwise the deposit will be applied to a late cancellation/no show fee if you are unable to attend your scheduled appointment.
I would like to schedule
Do you have a preferred doctor?
My ideal appointment would be on aMonday - Friday between Time and Time .
Another day that would work would be on aMonday - Friday between Time and Time .
Please include the following with my visit

VaccinationsNail TrimAnal Gland ExpressionEar CleaningCheck Lump(s)Heartworm TestOther
Additional notes for the visit
AUTHORIZATION
Type a question*

I HEREBY VERIFY THAT I AM ABOVE THE AGE OF 18 AND THE LEGAL OWNER OR AUTHORIZED REPRESENTATIVE FOR ALL PATIENTS LISTED. I FURTHER AUTHORIZE THE VETERINARIAN TO EXAMINE, PRESCRIBE FOR, AND/OR TREAT MY PETS. I ASSUME FULL RESPONSIBILITY FOR ALL CHARGES INCURRED IN THE CARE OF ALL MY PETS ON MY FILE. I ALSO UNDERSTAND THAT THESE CHARGES WILL BE PAID AT THE TIME OF RELEASE AND THAT A DEPOSIT MAY BE REQUIRED FOR SURGICAL TREATMENT OR HOSPITALIZATION. I ALSO UNDERSTAND AND AGREE TO A MINIMUM SERVICE CHARGE OF $5.00 WILL BE APPLIED TO ALL PAST DUE BALANCES OVER 30 DAYS OLD. I ASSUME RESPONSIBILITY FOR ANY COLLECTION CHARGES FOR A BALANCE DUE FOR ANY REASON.
SIGNATURE*

Clear
DATE OF SIGNATURE*

MonthDayYear
Date
Should be Empty:

Client Information

Patient Information

AUTHORIZATION