Client and Patient Information Form | Westside Animal Hospital

Please Note: Fields marked with an * are required.

*Please Choose One:

Pet OwnerBreeder

Primary Animal Caretaker Information

*Full Name:
*Address:
Lot/Apt #:
*City/State/Zip:
*County:
*Email Address:
Home Number:
Cell Number:
Employer:
Work Number:

Secondary Animal Caretaker Information (i.e. spouse)

Full Name:
Address (if different from above):
City/State/Zip:
Home Number:
Cell Number:
Employer:
Work Number:

How did you first hear about us?

Please select one:
If An Individual, whom may we thank:
If a Rescue Organization, which one:
If another hospital, which one:
If Other, please list:
Would you like reminders for your pet:
How would you prefer reminders delivered:

Emergency Contact

Emergency Contact #1

Name:
Relationship:
Number:

Emergency Contact #2

Name:
Relationship:
Number:

To help prevent the spread of infectious diseases, ALL hospitalized and boarded animals MUST be current on all vaccines.

YesNo

* I understand every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital care and handling. I hereby authorize the hospital to receive, prescribe for, treat or perform surgery upon the pet(s) listed below. Furthermore, I agree to pay fees for services rendered at the time the pet(s) is discharged from the hospital or the service is otherwise terminated. I agree to pay 33% of all incurred expenses to cover collection fees in the event that collection efforts become necessary. I understand that veterinary service is provided during the nighttime hours as necessary in the judgement of the veterinarian in charge. Continuous presence of qualified personnel may not be provided.

AgreeDisagree

* I grant permission to Westside Animal Hospital, its representatives and employees the right to take photographs of my pet, and to copyright, use and publish the same in print and/or electronically. I agree that Westside Animal Hospital may use such photographs of my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web/Social Media content.

Animal Medical History

Pet #1

*Pet's Name:
*Species (Dog, Cat, Bird, etc):
*Breed:
*Description (color):
*Age or Date of Birth:
*Sex:
*Spayed (female) or Neutered (Male):
*Microchipped:
If microchipped, what is the number:
Medical History-Prior Illness/Surgery:
*Reason for Visit:

Pet #2

Pet's Name:
Species (Dog, Cat, Bird, etc):
Breed:
Description (color):
Age or Date of Birth:
Sex:
Spayed (female) or Neutered (Male):
Microchipped:
If microchipped, what is the number:
Medical History-Prior Illness/Surgery:
Reason for Visit:

Pet #3

Pet's Name:
Species (Dog, Cat, Bird, etc):
Breed:
Description (color):
Age or Date of Birth:
Sex:
Spayed (female) or Neutered (Male):
Microchipped:
If microchipped, what is the number:
Medical History-Prior Illness/Surgery:
Reason for Visit:

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