New Client Registration

Owner Name*

First NameLast Name

Home Phone Number*

Cell Phone Number

Employer*

Business Name

Work Phone Number

Email*

example@example.com or declined@gmail.com. Providing your email will keep you up to date on closures and information pertaining to Animal Medical West. You will also receive reminders for appointments via email where you can confirm online!

My contact preference is*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

You emergency contact is authorized to pick up and/or approve treatments for the pets on your account

Emergency Contact Name

First NameLast Name

Emergency Contact Phone Number

The Emergency Contact is a/an

SpouseOther Family MemberFriend

We may offer treats during the appointment, does any person attending appointments have any allergies, such as nut allergies, that we should be aware of?*

Pet Information

Pet's Name*

Species*

CanineFeline

Breed*

Color*

Are they male or female?*

MaleFemale

Are they neutered/spayed?*

YesNo

Approximate Date of Birth/Age*

You may input approximate age if DOB not known

Are they on any medications?*

Do they have any known allergies, to vaccines or otherwise?*

Name of Previous Vet*

If you'd like us to add a photo of your pet to your account please attach one here.

If you have additional pets please input on the next page. If there are not enough spaces for the amount of pets you have please see the front desk about adding additional pets.

How did you hear about us?*

Social Media Consent*

I grant to Animal Medical West, its representatives and employees the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically. I agree that Animal Medical West may use such photographs of me and/or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and web content.I do not grant Animal Medical West the right to take photographs of me and/or my pet.

ALL FEES ARE DUE AND PAYABLE UPON COMPLETION OF SERVICES.

We do not provide payment plans, but we do accept Care Credit and Scratch Pay for veterinary services.

Methods of payment accepted: Cash, Check (except for the initial visit), Visa, Mastercard, Discover, American Express, Care Credit, and Scratch Pay.

I understand that in order to meet certain scheduling requirements, all missed appointments will be considered a “no-show” after 20 minutes unless advance notice is arranged. Clients not appearing for appointments may be assessed up to $56.00 per incident. I understand every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital care and handling. I hereby authorize this hospital to receive, prescribe for, treat or perform surgery upon the pet(s) listed above. Furthermore, I agree to pay fees for all services rendered at the time the pet is discharged from the hospital or the service is otherwise terminated. I agree to pay for the reasonable costs of collection, attorney fees, and court costs in the event that collection efforts become necessary. I agree that the venue of this action will be in the county where the hospital is located. I understand that veterinary service is provided during nighttime hours as necessary in the judgment of the veterinarian in charge. Continuous presence of qualified personnel may not be provided.

Owner Full Name*

First NameLast Name

Owner Signature*

Today's Date*

Date

**IF YOU HAVE ONLY ONE PET, PLEASE CLICK "SUBMIT" BELOW.

IF YOU HAVE MULTIPLE PETS PLEASE CLICK "NEXT" TO GO TO THE NEXT PAGE TO ADD MORE PET INFORMATION. DO NOT CLICK SUBMIT UNTIL YOU ARE FINISHED ADDING ALL PETS.