New Client Registration Form - Veterinary Specialty Center of Seattle

Client Information

Name

First Last

Please include your vehicle make/color:

Address

Street Address Address Line 2 City State ZIP Code

Phone Number (Best Contact #)

Phone Number (Alternate)

Email

Primary Care Information

Primary Care Veterinarian

Primary Care Veterinary Hospital

How did you hear about our hospital

Veterinary referral
Internet
Yellow pages
Other

Patient (Pet) Information

Name

Species

Breed

Gender

Male
Female

Spayed/Neutered*

Yes
No

Age/Date of Birth

Are your pet’s vaccinations up to date?

Yes
No
I don't know

Is your pet currently taking any medications?*

Yes
No
I don't know

Please list medication, if any:

Reason for appointment

In the event that cardiopulmonary resuscitation (CPR) is required for my pet, I authorize:*

CPR
No resuscitative efforts

I grant permission to Veterinary Specialty Center of Seattle to post a photograph of my pet and/or publish brief information about my pet’s story on-line or in print.*

I consent.
I DO NOT consent.

Payment is due at the time of service. A deposit is required if your pet is admitted to the hospital. Additional deposits may be required during hospitalization and payment of the balance in full is required at the completion of services or when your pet is discharged from the hospital.  We accept all major credit cards, checks and cash. One of our team members can provide you with information on healthcare financing resources (Care Credit, ScratchPay) as well as charitable organizations upon request.*

I understand and agree.
I DO NOT agree.