Welcome Form

Welcome Form

West Market Veterinary Hospital
Thank you for giving us the opportunity to care for your pet. Please take the time to fill in this form completely. If you do not have an appointment yet, please call 336-292-4753 before submitting this form.
REGISTRATION
Last Name*
First Name*
Date of Appointment*

MonthDayYear
If you do not yet have an appt, please call 336-292-4753
Address*
Zip Code*
E mail Address*
example@example.com
Home Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Spouse/Co Owner
Spouse/Co Owner Phone

Area CodePhone Number
Emergency Contact Name
Emergency Contact Phone

Area CodePhone Number
How did you learn of our clinic?*

WebsiteRecommendationPhone DirectorySignOther
If recommended, by whom?
# of Dogs in household
# of Cats in household
Other (specify)
Pet Health History

Please list pet health history below and bring any vaccine records or medical history with you to your visit.
Name of Pet Visiting*
Type of Pet*

DogCatOther
Breed*
Color*
Birthdate

MonthDayYear
Date
Age*
Spayed FemaleNeutered MaleNot Spayed FemaleNot Neutered Male
Please check any symptoms or problems that you have noticed with your pet.

Behavior ProblemsLack of AppetiteLimpingLoss of BalanceSneezingThirst and/or Urination IncreasedBleeding GumsBreathing ProblemsCoughingDiarrheaVomitingWeaknessScootingScratchingSeems DepressedShaking HeadEyes Bulging or BloodshotGaggingOther
Pet's current medications
Describe your pet's food
AUTHORIZATION
I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment.
Signature*
Date*

MonthDayYear
Date
Are you able to bring or email proof of rabies and/or vaccine history?*
Please send copy to westmarketvets@gmail.com
Should be Empty:

Welcome Form

REGISTRATION

Pet Health History

AUTHORIZATION