Form

New Client Intake Form
Owner Information
Owner First and Last Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Spouse's Name

First NameLast Name
Patient #1 Information
Patient Name
Species
Breed
Color
Date of Birth

MonthDayYear
Date
Age
Is your pet spayed/neutered/altered?
Has your pet been vaccinated within the last 12 months?
If so, which vaccines and when were they vaccinated?
Please list any ongoing or past medical conditions or problems:
Patient #2 Information
Patient Name
Species
Breed
Color
Date of Birth

MonthDayYear
Date
Age
Is your pet spayed/neutered/altered?
Has your pet been vaccinated within the last 12 months?
If so, which vaccines and when were they vaccinated?
Please list any ongoing or past medical conditions or problems:
How did you become aware of Wayside Animal Hospital?
Personal Recommendation (Who may we thank?)
Friend's Name, Doctor's Name, etc...
If you have an appointment already scheduled, please select the date below that you are ALREADY scheduled.

MonthDayYear
Date
Preferred form of payment
PAYMENT POLICY

PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED: I understand there will be a service charge of $35.00 on all returned checks. I will be responsible for payment of all charges incurred on behalf of this/these animals. A COLLECTION FEE WILL BE ADDED TO THE BALANCE OF ANY ACCOUNTS SENT TO THE COLLECTION AGENCY.
We use text (SMS) messaging to confirm appiontments and communicate lab results or messaging regarding your pet's care. Do we have your consent to contact you at the numbers above using text (SMS) messaging?
Please sign below in agreement with the payment policy listed above.
Should be Empty:

New Client Intake Form

Owner Information

Patient #1 Information

Patient #2 Information