New Client and Patient Form

Please fill out the new client and patient form.

Name*

Last NameFirst Name

Address*

Street Address Line 2

CityState

Zip

Home Phone

E-mail*

Cell Phone*

Alternate contact

I understand I will be paying a NON-REFUNDABLE deposit on my credit card that I provide to create and hold this appointment. If I do not arrive for this appointment, or
need to cancel within 24 hours of this appointment, my deposit will be forfeited. If I
give more than 48 hours notice (business days, M-F) of a change to the
appointment, I may rebook using this deposit. I agree to these terms.

Initial*

I understand the terms of this agreement, and agree to the NON-REFUNDABLE deposit - please initial above

*We work on an appointment basis and you are expected to be on time. This includes arriving 10 minutes early to verify information, and check you in..

Name

Sex

Breed

Spayed or Neutered?

Age (birthdate)

Color

Does your pet have a microchip?

Known medical conditions of your pet:

Reason for visit

PRIOR RECORDS:

*If your pet has any prior records please have your prior veterinary hospital email
those to us as soon as possible Contact@burienvet.com.

*If you would like us to contact your previous veterinarian for records, please list the hospital name and phone number below:

*If you have pet records at home, they will need to be provided to us at least 24
hours before your scheduled appointment.

Payment is expected at the time of service. We honor cash, check, Visa,
Mastercard, and Discover. In order to avoid misunderstandings, we urge all
charges be discussed with the doctor before services are performed. I agree.

I understand the terms of payments and agree to pay when treatment/services are rendered.
(Please initial below)

Initial*

Heartworm Test – Date

Results

FELV/FIV Test

Results

Flea Control Product

Any known medical history:

Payment is expected at the time of service. We honor cash, check, Visa, Mastercard, and Discover. In order to avoid misunderstandings, we urge all charges be discussed with the doctor before services are performed. I agree.

I understand the terms of payments and agree to pay when treatment/services are rendered. (Please initial below)

Please verify that you are human*

Client Information

Patient Information