WA001 - New Client Form

New Client Form

Medical Lake Veterinary Hospital
Your Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Format: (000) 000-0000.
Alternate Phone Number
Format: (000) 000-0000.
Email*
Secondary Contact
Secondary Contact Full Name
Phone Number
Format: (000) 000-0000.
Your Pet's Information
Name*
Species*
Breed*
Color/Markings
Sex
Neutered/Spayed
DOB/Age
Allergies
Special Considerations
Previous Vet/Hospital Name
May we contact them to get previous records?
Your 2nd Pet's Information
Name
Species
Breed
Color/Markings
Sex
Neutered/Spayed
DOB/Age
Allergies
Special Considerations
Previous Vet/Hospital Name
May we contact them to get previous records?
As the owner, or authorized agent, of the above named pet (s), I hereby consent and authorize the hospital to receive, prescribe, treat or operate on this pet (s). I give Medical Lake Veterinary Hospital, Overland permission to give my pet's medical history to other veterinary professionals when necessary. I understand that all fees are due and payable upon the release of the patient. If the patient has to be admitted for treatment, a deposit may be required at that time.
Signature

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Date

MonthDayYear
Should be Empty:

New Client Form