New Patient Information

Client / Owner Information

Your Name *

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Home Phone

Cell Phone

Work Phone

Your Email *

Is texting for reminders and pet's progress ok?

Yes

Emergency Contact Name

First

Last

Phone

Spouse / Co-Owner Information

Your Name

Cell Phone

Work Phone

Your Email

Pet Health History

Pet's Name

Type

Breed

Color(s)

Sex

Male

Female

Spayed/Neutered

Yes

Age

Current medications your pet is taking

Previous serious illnesses

Previous surgeries

Known allergies to vaccinations or medications

Previous Veterinarian

Marketing

How did you hear about us?

Doctor Referral

Doctor's Name

Hospital

City/Town

State/Province

Doctor Phone

Authorization

I hereby authorize the veterinarian to examine, prescribe for, and/or treat the the above described pet. I assume responsibility for all charges incurred in the case of the animal. I also understand that all professional fees are due at the time of services rendered.

Signature *

Sign above

Photo Release

I grant to Westmonte Animal Clinic, its representatives and employees the right to take photographs of me and/or my pet(s), and to copyright, use, and publish the same in print and/or electronically. I agree that Westmonte Animal Clinic may use such photographs of me and/or my pet(s) with or without my name and for lawful purpose, including for example, such purposes as publicity, illustration, advertising, and Web content including but not limited to all social media websites.

Photo Release Options

The above may take photos of your pet(s)

The above may NOT take photos of my pet(s)

Printed Name

Signature

Sign above

Date

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New Patient Information

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