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Wellshire Animal Hospital New Client Registration Form
Name of person responsible for medical and financial decisions for your pet.
*
First Name
Last Name
Spouse/partner Name: Anyone authorized to make medical or financial decisions for your pet.
First Name
Last Name
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Spouse/Partner's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Landline Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
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Emergency Contact Name: Person(s) authorized to make medical and financial decisions about your pets if we are unable to reach you during an emergency.
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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How did you hear about us?
Please Select
Referral
Google
Next Door
Other
Name of friend we should thank for the referral? We want to make sure they receive credit for referring you.
Other:
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Pet's Name:
*
Species: Dog, cat, etc.
*
Pet's Sex
*
Male
Female
I Don't Know
Is Patient Altered or Unsexed?
*
Spayed/Neutered
Intact
Not sure
Pet's Breed:
*
What Color is Pet?
*
Pet's Age: Please provide an approximate age or exact birthdate if you know it.
*
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Has Your Pet Been Seen At A Different Clinic?
*
Yes
No
Unknown
If Yes, Please list ALL clinics we will need to call for records. Please provide any different names they may be listed under if applicable.
*
Any other pets you would like to add to your account? Please include: Name, Male/Female, Spayed/Neutered/Intact/unknown, Species, Breed, Age, Color.
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Preferred Doctor
Please Select
Dr. Monica Watterud
Dr. Melissa Etheridge
Dr. Holly Cogswell
Dr. Andrea Carey
Dr. Laura Hedlin
Other:
Other:
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We want to show off your pet as a patient of Wellshire Animal Hospital, but we need your permission first. I grant permission to Wellshire Animal Hospital, it's employees, and authorized representatives to take photographs and/or video of me and/or my pet(s) to copyright, use and publish my pet's story, including relevant medical history. I agree that Wellshire Animal Hospital may use such photographs, videos, or stories including me and/or my pet with or without our names and for any lawful purpose, including for example such purposes as social media, publicity advertising, and other web content.
*
Yes
No
Does Your Pet Have Their Own Instagram or Facebook Account? Please List All Of Them So We Can Connect.
Upload image of your pet for their profile:
Browse Files
Drag and drop files here
Choose a file
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At Wellshire Animal Hospital, our top priority is providing excellent quality care for your pet. We realize that finances to provide that care may be a concern and we are committed to providing options that make veterinary care more accessible. PAYMENT IS DUE AT TIME OF SERVICE. IF YOU ARE UNABLE TO PAY TODAY, PLEASE DISCUSS OPTIONS WITH OUR STAFF PRIOR TO YOUR APPOINTMENT. Payment types accepted cash, checks, Visa, Mastercard, Discover, American Express and Care Credit. Care Credit MUST be APPROVED in advance of any services rendered. A $20 fee will be assessed for returned checks.
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I Accept
I Do Not Accept
We provide written treatment plans for any procedure UPON REQUEST. Treatment plans approximate total cost as closely as possible, however the final invoice may vary from the treatment plan. Treatment plan is only valid for 30 days. Deposits may be required for anesthetic procedures or any extensive care, for up to 75% of estimated costs for treatment. The remaining balance will be due at the time of discharge from the hospital.
*
I Accept
I Do Not Accept
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