New Client Form

New Client Form

Client (Owner) Information
Primary Owner

First NameLast Name
Primary Cell 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.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like to list anyone else on the account that can make medical decisions about your pet(s)?
Secondary Owner

First NameLast Name
I authorize the person listed above to make medical and financial decisions about my pet listed below:
PATIENT INFORMATION
Patient's Name:
Sex
Breed:
Color:
Age
Date of Birth

MonthDayYear
Date
Species
Microchip Number:
Is your pet currently on any medications? If yes, please list them below:
Please select any of the following symptoms that your pet may be experiencing:
Other:
Primary Care Veterinarian
Name/Phone
In the box below , please upload all prior records such as vaccinations, radiographs, and any other medical documents including any visits to a specialist.

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Upload your pet's picture

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I, the undersigned, owner of admitted patient or current guardian of patient, hereby authorize Palms West Veterinary Hospital and/or any authorized staff, to administer such treatment as is necessary, and to perform such additional procedures as are considered therapeutically and/or diagnostically necessary, and certify that no guarantee or assurance has been given as to the results that may be obtained. Further, I assume all financial responsibility for the charges incurred to this patient, consent to release medical information and authorize direct payment to Palms West Veterinary Hospital. I understand that I am fully responsible to pay for my examination today as well as any additional diagnostics, testing, or treatments that are provided to my pet. By signing this form, I realize that if I fail to pay today, I am liable for all collection costs, up to 100%, incurred for this account.
I consent to have photos and/or case study information pertaining to my Pet placed on our website or Facebook for education or informative purposes for our online users. Please select one of the following:
Please be aware we see scheduled appointments everyday; we offer walk-in availability as a convenience between our appointments whenever possible. Be aware the wait times will vary depending on how many patients are waiting to be seen; we kindly request that you call us in advance before coming in to ensure we are able to see your pet as a walk-in. We may also refer your pet out to a local emergency facility to ensure they receive the most appropriate and timely care in certain circumstances.
Client's Signature
Date

MonthDayYear
Date
Please verify that you are human
Should be Empty:

New Client Form

PATIENT INFORMATION