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Pre-Registration Form
Owner Information
Name
*
First
Last
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Cell Phone
*
Other Phone
Primary Phone
Cell
Other
For patient updates
Email
*
Other Authorized Representative
(if owner is not present)
Name
First
Last
Relationship
Primary Phone
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Email
Pet Information
Name
*
Pet
*
Dog
Cat
Breed
*
Color
*
Age
*
DOB
Vaccines Current?
*
Yes
No
Unknown
Gender
*
Female
Male
Spayed
Neutered
Unknown
List any current medications:
*
List any known allergies:
*
How did you hear about us?
Facebook/Instagram
Community Event
Primary Veterinarian
Pandora
Print
Radio
Sign/Drive by
TV
Web search
Word of Mouth
Primary Care Veterinarian Information
Name of Clinic/Hospital
*
Veterinarian
*
Phone Number (if known)
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Consent
*
I agree
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 professionals 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.
Consent
*
YES, I authorize Pacific Northwest Pet ER & Specialty Center to use my pet’s first name, photograph and clinical information.
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 shared through these sources.
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We are currently experiencing a large volume of cases and longer wait times. Please call ahead at 360-635-5302.
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