New Client Registration

Owner Name

First NameLast Name

Home Phone Number

Format: (000) 000-0000.

Cell Phone Number

Format: (000) 000-0000.

Employer

Business Name

Work Phone Number

Format: (000) 000-0000.

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

Format: (000) 000-0000.

The Emergency Contact is a/an

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

Breed

Color

Are they male or female?

Are they neutered/spayed?

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.

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, 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 15 minutes unless advance notice is arranged. Clients not appearing for appointments may be assessed up to $75.00 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.