New Patient Registration

West Coast Animal Hospital New Client/Patient Registration Form

5269 Linda Vista Rd
San Diego, CA 92110
United States
(619) 431-1423
staff@westcoast.vet

Please fill out this form with basic information about you and your pet(s).
Your Name*

First NameLast Name
Preferred Pronoun
Your Phone Number*
(555) 555-5555
Your Email*
example@example.com
Your Birthday*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address *
Alternate Contact Name

First NameLast Name
Alternate Contact Phone Number

Area CodePhone Number
Alternate Contact Email
example@example.com
How did you hear about us?*
If you referred by a current client, please enter their name below
Pet #1 Name*
Pet #1 Age/DOB*
Pet #1 Age/DOB*

MonthDayYear
Date
Pet #1 Species/Gender*
Pet #1 Breed*
Pet #1 Microchip Number
Pet #1 Color/Marking*

Pet #2
Pet #2 Name
Pet #2 Age/DOB
Pet #2 Age/DOB

MonthDayYear
Date
Pet #2 Species/Gender
Pet #2 Breed:
Pet #2 Microchip Number
Pet #2 Color/Marking

Rest of Form
May we contact your previous veterinarian for records?*

YesNo
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.*

YesNo
From time to time, our doctors may utilize an audio recording device for the explicit use of medical record transcription. The use of this device allows us to enhance the quality of our medical records and send detailed after visit summaries. If you do not consent to the use of such devices, you may not receive after visit summary communications.*

Yes, I consent to the use of an audio recording device to be used for medical record transcriptionNo, I do not consent to the use of audio recording for medical records and understand I may not receive detailed summaries as a result
CANCELLATION POLICY: 24 hours notice required for all cancellations. I agree to a $85 fee for late cancel/no show appointments, and $200 for dental/surgery cancellations. Specialist appointments require a $500 deposit and 48 hours notice of cancellation.*
Initial for Acknowledgement of Cancellation Policy
Exams, Consultations and Re-checks: The office visit charged is for an exam or consultation provided by the veterinarian. Additional follow up appointments or re-checks will incur a separate fee and are not included with the initial visit. Technician visit fees may also be charged for certain appointment types. *
Initial for Acknowledgement of Exam Policy
Financial Consent

We do our very best to provide you transparent costs and estimates for services. 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. As the client on the account for the pets listed above, I consent to full financial responsibility for services. I have read and understand the above statements and agree to all terms therein.
I have read to and agree to the payment policy stated above*
Initial for Financial Consent
Zero Tolerance Harrassment Policy

Our doctors and staff work very hard to care for your pets and meet your needs. We maintain a zero tolerance policy for any type of harrassing, harsh, abusive, threatening, discrimanatory, or otherwise unpleasant behavior directed towards them. This includes interactions in person, over the phone, via text, email, or through social media platforms. We reserve the right to refuse service to any client and will do so for these reasons.
I have read and agree to the zero tolerance harassment policy stated above*
Initial for Acknowledgement of Harassment Policy
Consent for Treatment/Hospitalization

AUTHORIZATION

I verify I am the Owner (or Authorized agent for the owner, at least 18 years or older) of the above named animal and authorize treatments to be performed. I authorize the use of intravenous fluids or medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure(s) as directed by the veterinarian. I have been advised as to the nature of my pet's condition and any procedures, diagnostics or treatments to be performed and the risks involved. I understand also that there is always a risk associated with any treatment or medication, even in apparently healthy animals and have discussed my concerns with the veterinarian. While I accept that all procedures will be performed to the best of the abilities of the veterinarians and staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I understand that any estimates provided for such procedures are for non-complicated procedures and that any unforeseen complications may result in additional costs. I understand that it may be necessary to provide medical and/or surgical intervention which were not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgment. I accept responsibility for any result in additional charges. I agree to be responsible for any charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital).
Client Signature: I have read and answered all of the above and agree to allow the doctors and staff West Coast Animal Hospital perform treatments and services for my pet(s). *

Clear
Today's Date*
Should be Empty: