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(310) 645-4444
8911 S. Sepulveda Blvd,
Los Angeles, CA 90045
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New Client Form
Required fields are marked {*}
Owner Information
Owner Name
*
First
Last
Owner's Date of Birth
*
The State of California requires DOB to dispense controlled substances
MM slash DD slash YYYY
Any Authorized Guardians:
Are you the legal owner(s) of the Animal(s)
*
Yes
No
Owners Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Phone
*
Is the Primary Phone a Cell Phone?
*
Yes
No
Secondary Phone
Check here to sign up for text reminders
Yes I Want Text Reminders
Owner Email
*
For copy of this form and future email correspondents.
Check here to sign up for email reminders.
Yes I Would Like Email Reminders
What are we seeing your pet for today?
*
How did you become aware of our clinic?
*
Website
Sign
Facebook
Google
Referral
Other
Whom can we thank for your visit?
*
Pet Information
Pet Name
*
Species
*
Dog
Cat
Breed
*
Color markings
*
Date of birth or age
*
Sex
*
Male
Female
Spay or neutered?
*
Yes
No
Name of previous vet?
*
Would you like us to request medical records from previous caregiver?
*
Yes
No
Would you like to add a second pet?
*
Yes
No
Second Pet Name
*
Second pet species?
*
Dog
Cat
Breed
*
Color markings
*
Date of birth or age
*
Sex
*
Male
Female
Spay or neutered?
*
Yes
No
Name of previous vet?
*
Would you like us to request medical records from previous caregiver?
*
Yes
No
Would you like to add a third pet?
*
Yes
No
Third Pet Name
*
Third pet species?
*
Dog
Cat
Breed
*
Color markings
*
Date of birth or age
*
Sex
*
Male
Female
Spay or neutered?
*
Yes
No
Name of previous vet?
*
Would you like us to request medical records from previous caregiver?
*
Yes
No
Make my pet a social media star! I authorize and grant Westchester Veterinary Center permission to take a picture of my pet and use it on Social Media (Facebook, Instagram, Twitter, etc.)
*
Yes
No, Thank You
AUTHORIZATION
*
I hereby authorize Westchester Veterinary Center and Cat Clinic to render medical care for my pet(s) as deemed necessary by the veterinarian. I assume responsibility for all charges occurred in the care of the pet(s). I also understand that all fees are due at the time of service. It is our policy to provide a written estimate of fees for any case where in-hospital treatment, emergency care, surgery or hospitalization will be provided. A deposit may be required depending upon the amount of the estimate. All fees are due upon release of patient.
Your Name here represents your Digital Signature
*
By signing this document you agree to accepting all financial responsibility for any and all treatments performed, and that you are at least 18 years of age or older.
First
Last
Date
*
MM slash DD slash YYYY
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Phone
This field is for validation purposes and should be left unchanged.
