Pre-Registration - Pacific Northwest Pet ER & Specialty Center

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*

Employer

Employer Phone

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?

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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Pre-Registration Form

Owner Information

Other Authorized Representative

Pet Information

Primary Care Veterinarian Information

EMERGENCY REFERRAL NOTICE: