Mon:
7:30 AM – 8:00 PM
Tue – Fri:
7:30 AM – 6:00 PM
Sat:
8:00 AM – 1:00 PM
425-485-6575
6630 NE 181st St. Suite F103,
Kenmore, WA 98028-4852
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New Client Form
Client Information
Date
*
Owner's Name
*
Home Address
*
Primary Phone Number
*
Alternative Phone Number
Email Address
*
Place of Employment
Work Phone Number
Spouse/Partner/Co-Owner Name
Spouse/Partner/Co-Owner Phone Number
Emergency Contact Name
Emergency Contact Phone Number
Do you have pet insurance? If yes, what is the name of the pet insurance?
How did you hear about us?
*
Used our services before
Referral
Google
Facebook
Business Directory (Yelp, Angie's List, Yellow Pages, etc.)
Online Ad
Print Ad
Direct Mailer
Community Event
Drive By
Other
Whom can we thank?
Pet Information
Pet Name
*
Species
*
Cat
Dog
Breed
*
Color/Markings
*
Birthday/Age
*
Sex
*
Male
Female
Is your pet spayed/neutered?
*
Yes
No
I don’t know
Dog Vaccines
For dogs, please confirm which vaccines are current for your pet.
Rabies Vaccine
Current
Not Current
I Don't Know
DHPP Vaccine (Distemper)
Current
Not Current
I Don't Know
Bordetella Vaccine
Current
Not Current
I Don't Know
Canine Influenza H3N2 & H3N8 Vaccine
Current
Not Current
I Don't Know
Leptospirosis Vaccine
Current
Not Current
I Don't Know
Cat Vaccines
For cats, please confirm which vaccines are current for your pet.
Rabies Vaccine
Current
Not Current
I Don't Know
FVRCP Vaccine
Current
Not Current
I Don't Know
Feline Leukemia Vaccine
Current
Not Current
I Don't Know
Pet Medical History
Any known allergies?
Any chronic health problems?
Is your pet microchipped?
*
Yes
No
No, but I'd like to get my pet microchipped.
Should your pet be muzzled?
*
Yes
No
Has your pet been seen by a veterinarian previously? If yes, please fill in the name of the clinic. If no, please type "No."
*
Reason for today's visit or any other questions/comments.
Authorization
We may need to contact you about your pet’s health, please consent by selecting the best method(s) of communication:
*
Home Address (Mail)
Primary Phone Number
Work Phone Number
Text Message
Permission to share your records with Other Hospitals/Emergency/Specialty?
Yes
No
Permission to share your records with Groomers/Daycare?
Yes
No
Permission to share your records with Pet Insurance?
Yes
No
Media Consent
Yes, I consent.
No, I do not consent.
I grant to Kenmore Veterinary Hospital, its representatives and employees the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically. I agree that Kenmore Veterinary Hospital may use such photographs of me and/or my pet with or without my name and for any lawful purpose, including but not limited to publicity, illustration, advertising, and web content.
Authorization
Yes, I authorize.
No, I do not authorize.
I, the undersigned, do hereby certify that I am the owner, or assuming responsibility, financial or otherwise, for the animal being presented to Kenmore Veterinary Hospital for the treatment of care. I hereby consent and authorize Kenmore Veterinary Hospital to receive, prescribe for or treat, as indicated, this animal presented. It is thoroughly understood that I assume all risks. I agree, if appropriate, to pick up this animal at the designated date and time agreed to by myself and Kenmore Veterinary Hospital. If in the event that the animal is not picked up, there will be a notice of 10-days to come claim the animal or it will be considered abandoned. The animal will be held in the manner that is considered to be most appropriate for the animal and the hospital. It is understood that I am not released from costs associated with the care of the pet. We do not bill and all fees are due when services are rendered. Deposits are required for all hospitalized patients. Our Hospital only accepts cash, personal checks (driver’s license required), Visa/MasterCard, American Express, Discover Card, Scratchpay, and Care Credit. I understand that if I do not pay my balance in full, that I am responsible for all statement fees, finance charges, and attorney/collection fees.
Phone
This field is for validation purposes and should be left unchanged.