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Having an Emergency?
About
About Us
Our Team
Join Our Team
Specials
Testimonials
Our Location
Services
Wellness Care
Surgery
Dentistry
Senior Care
Digital Radiology
Nutrition
Resources
New Clients
Online Forms
Payment Options
Outside Resources
Blog
Veterinary Education Library
Contact Us
Book Appointment
Having an Emergency?
Book Appointment
Online Pharmacy
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Having an Emergency?
Payment Options
Online forms
Pay Bill Now
Review Us
Facebook
Yelp
Book Appointment
Online Pharmacy
download
OUR
APP
About
About Us
Our Team
Join Our Team
Specials
Testimonials
Our Location
Services
Wellness Care
Surgery
Dentistry
Senior Care
Digital Radiology
Nutrition
Resources
New Clients
Online Forms
Payment Options
Outside Resources
Blog
Veterinary Education Library
Contact Us
Book Appointment
Having an Emergency?
About
About Us
Our Team
Join Our Team
Specials
Testimonials
Our Location
Services
Wellness Care
Surgery
Dentistry
Senior Care
Digital Radiology
Nutrition
Resources
New Clients
Online Forms
Payment Options
Outside Resources
Blog
Veterinary Education Library
Contact Us
Book Appointment
Having an Emergency?
BY APPOINTMENT ONLY
Mon-Fri: 8:00 AM – 5:30 PM
Sat & Sun: Closed
(425) 485-6575
6630 NE 181st St.
Kenmore, WA 98028
BY APPOINTMENT ONLY
Mon-Fri: 8:00 AM – 5:30 PM
Sat & Sun: Closed
(425) 485-6575
6630 NE 181st St.
Kenmore, WA 98028
New Patient Form
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Patient Information
Date
*
Owner's Name
*
Preferred Pronouns
*
She/Her
He/Him
They/Them
Home Address
*
Primary Phone Number
*
Alternative Phone Number
Email Address
*
Enter Email
Confirm Email
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?
*
Referral from Friend
Referral from Veterinary Hospital
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Facebook Ad
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Please Specify
*
Promotion Code
*
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
Pet Medical History
Any known allergies?
Any chronic health problems?
Is your pet microchipped?
*
Please Select
Yes
No
No, but I'd like to get my pet microchipped.
Should your pet be muzzled?
*
Please Select
Yes
No
Has your pet been seen by a veterinarian previously?
*
Yes
No
Previous veterinarian(s) or clinic(s). List all if more than one.
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?
Please Select
Yes
No
Permission to share your records with Groomers/Daycare?
Please Select
Yes
No
Permission to share your records with Pet Insurance?
Please Select
Yes
No
Media Consent
Please Select
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
Please Select
Yes, I authorize.
No, I do not authorize.
I 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 to 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.
BY APPOINTMENT ONLY
Mon-Fri: 8:00 AM – 5:30 PM
Sat & Sun: Closed