Client Information Form

Client Information Form

(to be completed by new clients, clients with new pets or clients with change of contact information)
Full Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Primary Email Address
You will be receiving important health information at this email address.
Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Employer's Name
Employer's Phone Number
Spouse/Partner Name
Spouse/Partner's Cell Phone

Area Code Phone Number
Spouse/Partner's Employer's Name
Spouse/Partner's Employer's Phone

Area Code Phone Number
How Did You Find Us?
If referred, by whom? We want to thank them!
Thank you for choosing Eastside Animal Hospital for your pet’s healthcare needs. In order to maintain the health of our practice fees are due at the time services are rendered. We will gladly prepare a treatment plan once your pet’s needs have been determined. We accept major credit cards and Care Credit. Returned checks and unpaid balances are subject to service charges.
Please indicate your primary choice of payment: Cash/Check, Credit Card, Care Credit

Cash/Check Credit Card Care Credit
Contact, Records and Risk Info
- We may contact you via e-mail
- Share your pet’s vaccination information with other boarding or grooming facilities and veterinary facilities
- Use photos of you and your pet(s) for medical record, marketing, or other educational purposes
- You understand that there may be risk involved in any procedure and no guarantee is made as to the results or outcome.
Click to acknowledge contact, records and risk info agreement. *

Yes, I acknowledge this agreement

Client Information Form

Patient Information