Client Information

If you will have more than one (1) pet with you, please fill out an additional form.

2) Owner Title

   Mr.    Mrs.    Miss.    Ms.    Dr.

3) Spouse/Co-Owner

4) Street Address

5) City 6) State 7) Zip

8) E-Mail Address 9) Cell Phone #

10) Telephone: Work Home

11) How did you first hear about our clinic?

   Street Sign    Yellow Pages    Website    Friend

   Another Doctor Other

Patient Information

1) Pet Name

2) Date of Birth

3) Species    Cat   Dog

4) Breed

5) Sex
  Male   Female
    Neutered
  Yes   No
    Spayed
  Yes   No

6) Color

7) Comments
     (Example: Medication, Special Diets, Etc.)

8) Previous Vaccination History & Dates
     (Example: Rabies - 6/03 , Fel Leukemia - 10/4)

I UNDERSTAND West Lynn Veterinary Clinic can set my pet up in their COMPUTERIZED REMINDER SYSTEM for all necessary EXAMINATIONS and VACCINATIONS. A reminder card is sent at the appropriate time.

(Please make a selection and enter your initials.)
YES, I want my pet’s records included in your reminder system.
NO, I do not want my pet’s records included in your reminder system.

Initials

Payment Policy
All fees and charges are due and payable upon release of patient unless PRIOR arrangements
have been made.  Any balance forward is subject to finance charges.
Cash, Check, Visa, Mastercard, American Express accepted.

Signature

(Your typed full name will serve as your signature)