New Client Form

Please fill out our online New Client Info Form below.

You may also download the PDF version of the form. Please complete and bring the form (and your pet) to your first appointment with us.

 


Client Information

Your Name*

Address*

City*

State*

Zip*

Occupation

Email Address*

Your Phone Number*

CellWorkHome

Spouse/Partner Name

Spouse/Partner Phone Number

CellWorkHome

Pet Information

Pet's Name*

Pet's Approximate Weight

Age or Date of Birth*

Species*

CanineFeline

Breed*

Color*

Male IntactMale NeuteredFemale IntactFemale Spayed

Does your pet have a history of seizures? NoYes

Has your pet had any adverse reaction to anesthesia or medication?
If so, please describe.*

Please list any medication or supplements that your pet is taking now or has taken within the past 2 weeks.*

Referring Veterinarian and Hospital Name

Regular Veterinarian and Hospital Name (if different from above)

How did you hear about us? (check all that apply)*

My VeterinarianAnimal Medical Center of SeattleFriend/Family MemberYelpGoogle/Search EngineFacebookOther Online SourceCommunity EventOther

If other please specify:

We often take pictures of our hospitalized patients and post stories on our website, Facebook or Instagram. Do you authorize use of pictures of your pet for this purpose only?

YesNo