New Patient Form - Pacific Northwest Pet ER & Specialty Center

Owner Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone*

Other #*

Primary # (for patient updates)*

Cell
Other

Email*

Other Authorized Representative

(if owner is not present)

Name*

First Last

Relationship*

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Pet Information

Name*

Name

Dog
Cat

Breed*

Color*

Age*

DOB*

Vaccines Current?*

Yes
No
Unknown

Gender*

Male
Female
Spayed
Neutered
Intact
Unknown

Reason(s) for visit:*

List any current medications:*

List any known allergies/food allergies:*

Who is your pet insurance carrier?

Regarding your pet insurance:*

I do not have pet insurance.
Please check this box to authorize consent for the above described pet's insurance records to be shared with Pacific Northwest Pet ER & Specialty Center.

How did you hear about us?*

Primary Care Veterinarian Information

Name of Clinic/Hospital*

Veterinarian*

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Consent

Yes, I authorize Pacific Northwest Pet ER & Specialty Center to use my pet's first name, photograph and clinical information

I hereby authorize the veterinarian to examine, prescribe for, and/or treat the above described pet and provide any pertinent medical records to other Veterinarians or medical professional involved in my pet's care unless requested otherwise. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid when services are rendered and that a deposit may be required for treatment.

Pacific Northwest Pet ER & Specialty Center requests permission to use information for internal and external use such as: research, education and social media. I authorize the use of my pet's first name, photograph and clinical information (including at times medical condition, treatment and prognosis). Under no circumstances will my name, my personal or financial information be shard through these sources.

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Email

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