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New Client Form
Client (Owner) Information
Primary Owner
*
First Name
Last 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
City
State / Province
Postal / Zip Code
Would you like to list anyone else on the account that can make medical decisions about your pet(s)?
*
Yes - Please List Below
No
Secondary Owner
First Name
Last Name
I authorize the person listed above to make medical and financial decisions about my pet listed below:
PATIENT INFORMATION
Patient's Name:
Sex
Male
Female
Neutered Male
Spayed Female
Breed:
Color:
Age
*
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Date of Birth
-
Month
-
Day
Year
Date
Species
*
Please Select
Canine (Dog)
Feline (Cat)
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:
Behavioral Changes
Weakness
Weight Loss or Gain
Depression
Seizures
Loss of Appetite
Coughing or Sneezing
Vomiting
Diarrhea
Limping
Gagging
Increased Urination
Itching / Scratching
Increased Thirst
Breathing Issues
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.
*
Agree
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:
*
Yes
No
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.
*
Acknowledge
Client's Signature
*
Date
*
/
Month
/
Day
Year
Date
Please verify that you are human
*
Submit
Submit
Should be Empty: