New Client Form

My contact preference is

Address

You emergency contact is authorized to pick up and/or approve treatments for the pets on your account

The Emergency Contact is a/an

SpouseOther Family MemberFriend

We may offer treats during the appointment, does any person attending appointments have any allergies, such as nut allergies, that we should be aware of?

Pet Information

Species

CanineFeline

Are they male or female?

MaleFemale

Are they neutered/spayed?

YesNo

Are they on any medications?

Do they have any known allergies, to vaccines or otherwise?

If you'd like us to add a photo of your pet to your account please attach one here.

How did you hear about us?

Social Media Consent

I grant to Animal Medical West, its representatives and employees the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically. I agree that Animal Medical West may use such photographs of me and/or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and web content.I do not grant Animal Medical West the right to take photographs of me and/or my pet.

ALL FEES ARE DUE AND PAYABLE UPON COMPLETION OF SERVICES.

We do not provide payment plans, but we do accept Care Credit and Scratch Pay for veterinary services.

Methods of payment accepted: Cash, Check (except for the initial visit), Visa, Mastercard, Discover, American Express, Care Credit, and Scratch Pay.

I understand that in order to meet certain scheduling requirements, all missed appointments will be considered a “no-show” after 20 minutes unless advance notice is arranged. Clients not appearing for appointments may be assessed up to $43.00 per incident. 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 this hospital to receive, prescribe for, treat or perform surgery upon the pet(s) listed above. Furthermore, I agree to pay fees for all services rendered at the time the pet is discharged from the hospital or the service is otherwise terminated. I agree to pay for the reasonable costs of collection, attorney fees, and court costs in the event that collection efforts become necessary. I agree that the venue of this action will be in the county where the hospital is located. I understand that veterinary service is provided during nighttime hours as necessary in the judgment of the veterinarian in charge. Continuous presence of qualified personnel may not be provided.