West Seattle Animal Hospital

4700 42nd Avenue SW, Ste 210
Seattle, WA 98116

(206)932-3308

westseattleanimal.com

New Client Registration

PLEASE FILL THIS FORM OUT AT LEAST 2 HOURS PRIOR TO YOUR APPOINTMENT TIME!
If your appointment time is within 2 hours from now, please do not fill this online form out. Instead, please arrive at our facility 15-20 minutes prior to your appointment to fill out paperwork. Thank you!
First Name of Primary Pet Owner (required)

Last Name (required)

Middle Name or Initial (required)

Name of spouse, partner or co-owner of pet (First and Last)

Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Primary Contact Number (required)
Phone TypePhone Number (required)
Alternate Contact Number
Phone TypePhone Number
Email Address (required)

Driver's License Number and Issuing State (required)

Employer (required)

Employer Phone Number

Emergency Contact
Who should we contact in case of emergency (other than you or your spouse/partner)?

Phone number for emergency contact

Pet Information
Pet's Name (required)

Species (required) :
Breed(s) (required)

Gender (required) :
Primary Coat Color (required) :
Secondary Coat Color :
Coat Characteristics (required) :
Date of Birth (approximate age ok) (required) :
Is your pet microchiped? (required) :
If yes, microchip number (We can scan your pet once you arrive if you don't know the number)

Second Pet Info
Pet's Name

Species :
Breed(s)

Gender :
Primary Coat Color :
Secondary Coat Color :
Coat Characteristics :
Date of Birth (approximate age ok) :
Is your pet microchiped? :
If yes, microchip number (We can scan your pet once you arrive if you don't know the number)

Third Pet Info
Pet's Name

Species :
Breed(s)

Gender :
Primary Coat Color :
Secondary Coat Color :
Coat Characteristics :
Date of Birth (approximate age ok) :
Is your pet microchipped? :
If yes, microchip number (We can scan your pet once you arrive if you don't know the number)

Appointment Options
This helps us match your registration to your appointment (required) :
If you have an appointment already please enter the Date & Time you are scheduled for:

Referral information
What is the name and city/state of your prior veterinary care office?

How did you hear about us? (required)
(Select all that apply)
Our website
Location
Google
Other Internet search engine
Yelp
Friend, Neighbor or Family Member
Phone Book
Animal Shelter or Rescue Group
Coupon
Other
May we thank a specific person or business for referring you?

Payment and Fee Information
Payment is due in full at the time of service.
We do not provide billing services. Upon request, we will provide you with a written estimate for your pet's care. A deposit may be required prior to treatment. We accept cash, debit cards, Visa, Mastercard, American Express, Discover and Care Credit. Checks may be accepted at our discretion. Returned checks will incur a service charge of $25. Unpaid accounts are assigned to a collection agency and may incur additional charges such as interest and legal fees.
Select one: (required)
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