Eastside Animal Medical Center

Primary Owner's Name

Best Contact Number

Secondary Owner's Name

Secondary Contact Number

Address

Street Address Line 2

City, State, Zip

Email

example@example.com

How did you hear about us?

GoogleSign/LocationFacebookMailers

Personal Recommendation

Other

Are you an EDUCATOR or EMERGENCY SERVICE?

YesNo

Have you been to a veterinarian before?

YesNo

If yes, which one

May we post your pet(s) on our Social Media pages?

YesNo

Pets Name

Date of birth / Age

Species

CanineFeline

Breed

Color / Markings

Gender / Altered

MaleFemaleSpayedNeutered

Has your per ever needed sedation, medications, or muzzle for preventative care, like physical exams, vaccines, or even nail trims?

YesNo

If yes, please explain

Checking in multiple pets? Please fill out next pet information. Otherwise, pelase skip this section.

Pet's Name

Date of Birth / Age

Species

CanineFeline

Breed

Color / Markings

Gender / Altered

MaleFemaleSpayedNeutered

Has your per ever needed sedation, medications, or muzzle for preventative care, like physical exams, vaccines, or even nail trims?

YesNo

If yes, please explain

Method of Payment **PAYMENT IS DUE AT TIME SERVICES ARE RENDERED**

For you convenience, we accept Visa/MasterCard/Amex/Discover/Cash/ApplePay/CareCredit.We do not accept payment plans though our hospital, but we do accept CareCredit and ScratchPay as other payment options.

Appointment Policy: In an effort to ensure efficient and respectful scheduling practices, our veterinary clinic has implemented a policy of requiring a non-refundable reservation fee. This policy has been implemented to mitigate the negative impact of no-call, no-show appointments, which not only result in wasted resources but also prevent other pets in need from receiving timely care. By requiring a non-refundable reservation fee, we hope to encourage accountability and encourage clients to reschedule or cancel appointments in a timely manner, allowing us to better serve our patients and provide exceptional medical care.

Signature

Date

Eastside Animal Medical Center

CLIENT INTAKE FORM