New Patient Registration Form
Please fill out this form with basic information for you and your pet(s)
Your Name
*
First Name
Last Name
Your Phone Number
*
(555) 555-5555
Your Email
*
example@example.com
Your Birthday
*
ex. 08/21/1984
Your Birthday
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Address
*
Alternate Contact Name
First Name
Last Name
Alternate Contact Phone Number
-
Area Code
Phone Number
Alternate Contact Email
example@example.com
How did you hear about us?
*
Google
Yelp
Humane Society
Another Animal Hospital / Veterinarian
Word of Mouth / Recommendation
Social Media (Facebook, Nextdoor, etc.)
Local News
Sign
Other / Unknown
Pet #1 Name
*
Pet #1 Age/DOB
*
Pet #1 Age/DOB
*
-
Month
-
Day
Year
Date
Pet #1 Species/Gender
*
Dog--Female
Dog--Female, Spayed
Dog--Male
Dog--Male, Neutered
Cat--Female
Cat--Female, Spayed
Cat--Male
Cat--Male, Neutered
Other
Pet #1 Breed
*
Pet #1 Microchip Number
Pet #1 Color/Marking
*
Pet #2
Pet #2 Name
Pet #2 Age/DOB
Pet #2 Age/DOB
-
Month
-
Day
Year
Date
Pet #2 Species/Gender
Dog--Female
Dog--Female, Spayed
Dog--Male
Dog--Male, Neutered
Cat--Female
Cat--Female, Spayed
Cat--Male
Cat--Male, Neutered
Other
Pet #2 Breed:
Pet #2 Microchip Number
Pet #2 Color/Marking
Rest of Form
May we contact your previous veterinarian for records?
*
Yes
No
Previous veterinarian
We LOVE pets on social media! Do you authorize West Coast Animal Hospital, its representatives and employees the right to take photographs of me and/or my pet, and to copyright, and use/publish for any lawful purpose, including web content and advertising.
*
Yes
No
CANCELLATION POLICY: 24 hours notice required for all cancellations. I agree to a $70 fee for late cancel/no show appointments, $200 for specialist appointments, and $200 for dental/surgery cancellations.
*
Initial for Financial Consent
Payments:
All payments are due at the time of services rendered. We accept all major credit cards. Payment plans for Scratch Pay & Care Credit can be approved in as little as 10 minutes and are subject to limitations. I have read and understand the above statements and agree to all terms therein.
Signature
*
Clear
*
Submit
Should be Empty: