New Client/Pt Form

New Client Form
Date*

MonthDayYear
Date
Name*

First NameLast Name
Significant Other

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Preferred Method of Contact*
Client Birth Date (your birthday not the patient)*

MonthDayYear
Date
Please list any additional parties that have the authority to authorize treatments and make financial decisions on your behalf:
How did you hear about our hospital:*
If a current client referred you to us, please list their name.
Do you have a Pet Insurance Provider?*

YesNo
Eastside Animal Hospital may use photographs of your pet for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and web/social medica content
I understand that Eastside Animal Hospital does not set up accounts and all services will be paid in full at the completion of each visit. Estimates for recommended services and procedures can be given prior to the start of any treatments.
Pet Name*

New Client Form