New Client Information Form
Thank you for choosing Westchase Veterinary for your pets' care. Please take a few minutes to fill out the following information.
Do you already have your pet's first appointment scheduled?
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Yes
No
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Appointment Information
Please note, if you have more than one appointment scheduled, please select your first appointment.
What date is your appointment scheduled for?
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Month
-
Day
Year
Date
What time is your appointment scheduled for?
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1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
30
Minutes
AM
PM
AM/PM Option
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Client Contact Information
Primary Owner's Name
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First Name
Last Name
Secondary Owner's Name
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Owner's Phone Number
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Area Code
Phone Number
Primary Owner's Phone Number is a:
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Home Phone
Cell Phone
Work Phone
Spouse's Primary Phone Number
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Area Code
Phone Number
Spouse's Primary Phone Number is a:
Home Phone
Cell Phone
Work Phone
Alternate Phone Number
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Area Code
Phone Number
Alternate Phone Number is a:
Home Phone
Cell Phone
Work Phone
Email Address
example@example.com
What is your preferred method of contact?
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Call Primary Owner's Phone
Text Primary Owner's Phone
Call Secondary Owner's Phone
Text Secondary Owner's Phone
Email
Primary Owner's Employer's Name, Address
Secondary Owner's Employer's Name, Address
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Emergency Contact Information
In the event owe needed to reach you but were unable, who would you like us to contact (other than the owners).
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
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Area Code
Phone Number
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Referral Information
How did you hear about Westchase Veterinary Center? (Please check all that apply)
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Location, sign, walk-in
Saw ad in newspaper or magazine
Received flyer in the mail
Social media (Facebook, Twitter, Instagram)
Our website or internet search
Broadcast (Radio, TV)
Customer review site (Google, Yelp, etc)
Word of mouth (friend, relative, neighbor, etc)
Referred by a veterinarian
Referred by a business
If you were referred by a person or business, who may we thank?
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Pet Information
Please tell us about the pets currently residing in your household.
Pet's Name
*
Pet's Species
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Canine
Feline
Pet's Breed
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Pet's Age or Date of Birth
*
Is this pet male or female?
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Male
Female
Has this pet been spayed or neutered?
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Yes
No
Is there a veterinarian you would like us to contact for your pet's previous medical records?
Clinic(s) Name and Phone Number
Do you have additional pets?
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Yes
No
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Pet Information
Please tell us about the pets currently residing in your household.
Pet's Name
*
Pet's Species
*
Canine
Feline
Pet's Breed
*
Pet's Age or Date of Birth
*
Is this pet male or female?
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Male
Female
Has this pet been spayed or neutered?
*
Yes
No
Is there a veterinarian you would like us to contact for your pet's previous medical records?
Clinic(s) Name and Phone Number
Do you have additional pets?
*
Yes
No
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Pet Information
Please tell us about the pets currently residing in your household.
Pet's Name
*
Pet's Species
*
Canine
Feline
Pet's Breed
*
Pet's Age or Date of Birth
*
Is this pet male or female?
*
Male
Female
Has this pet been spayed or neutered?
*
Yes
No
Is there a veterinarian you would like us to contact for your pet's previous medical records?
Clinic(s) Name and Phone Number
Do you have additional pets?
*
Yes
No
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Pet Information
Please tell us about the pets currently residing in your household.
Pet's Name
*
Pet's Species
*
Canine
Feline
Pet's Breed
*
Pet's Age or Date of Birth
*
Is this pet male or female?
*
Male
Female
Has this pet been spayed or neutered?
*
Yes
No
Is there a veterinarian you would like us to contact for your pet's previous medical records?
Clinic(s) Name and Phone Number
Do you have additional pets?
*
Yes
No
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Next
Pet Information
Please tell us about the pets currently residing in your household.
Pet's Name
*
Pet's Species
*
Canine
Feline
Pet's Breed
*
Pet's Age or Date of Birth
*
Is this pet male or female?
*
Male
Female
Has this pet been spayed or neutered?
*
Yes
No
Is there a veterinarian you would like us to contact for your pet's previous medical records?
Clinic(s) Name and Phone Number
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Financial Policy
Our policy is to provide you with a written estimate of fees recommended for in-clinic treatment, emergency care, surgery, and/or hospitalization. A deposit will be required prior to any treatment and/or for all pets requiring overnight care or hospitalization.
Name of person responsible for treatment and financial decisions on this account.
*
First Name
Last Name
Date of birth of person responsible for treatment and financial decisions on this account.
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-
Month
-
Day
Year
Date
Is there another responsible party?
*
Yes
No
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Financial Policy
Our policy is to provide you with a written estimate of fees recommended for in-clinic treatment, emergency care, surgery, and/or hospitalization. A deposit will be required prior to any treatment and/or for all pets requiring overnight care or hospitalization.
Name of person responsible for treatment and financial decisions on this account.
*
First Name
Last Name
Date of birth of person responsible for treatment and financial decisions on this account.
*
-
Month
-
Day
Year
Date
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Agreement of Policies
I have read and understand the above policies and request treatment for my pet in accordance with these policies. I assume financial responsibility for all charges incurred to the patient (pet), and agree to pay all costs of collection and/or fees in the event of non-payment.
Please type your name below to agree to the above terms.
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Date
*
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Month
-
Day
Year
Date
Submit
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