New Clients : New Clients

New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

Form - New Client

Your name (the legal owner of animal): (required)
First Name (required)
Last Name (required)
Your current address: (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Daytime phone: (required)
Phone TypePhone Number (required)
Evening phone: (required)
Phone TypePhone Number (required)
Please list the best email address where we may contact you: (required) :
Your pet's name: (required)

This pet's age (in years) or date of birth: (required)

Species / Type of animal: (required)
Canine (dog)
Feline (cat)
Avian (bird)
Rabbit
Ferret
Guinea Pig
Rat
Mouse
Hamster
Gerbil
Lizard
Snake
Other (please specify under "Breed")

Breed (if applicable):

Sex: (required)
Male
Female

This pet's current reproductive status: (required)
Spayed or neutered
Intact (this pet has not been spayed or neutered)

Please check if your pet is currently up-to-date on his/her vaccines (applies to dogs/cats/ferrets)
Please check if you have copies of your pet's medical records
Has your pet ever been examined by a veterinarian before? (required)
Yes
No

Please list the name(s) of previous veterinary practice(s) where this pet has been seen: (required)

May we request a copy of your pet's previous medical records, to better understand his/her health? (required)
Yes
No

Please check if you would like to make an appointment, so that our staff may contact you.
Please list the reasons or conditions that are prompting your visit: (required)

Any special requests or previous medical conditions that we should know about?

Please list additional pets here (optional):

Please read the financial policy and indicate below:
I understand, by indicating "I Agree" and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the staff of Chimacum Valley Veterinary Hospital and Pet Townsend Veterinary Clinic, and that charges are due and payable at the time of service, unless other arrangements are made before examinations or services are performed. I understand that I can request an estimate for costs associated with examinations and medical services before those services are performed. I understand that any balance carried over a period of 30 days will accrue a monthly finance charge, and any balance unpaid over 90 days will be forwarded to a collection agency.
I have read the above statement, and (required)
I Agree
I Disagree


The verification code below ensures the form is not submitted by a computer
Verification Code :
Enter the code you see in the graphic below in this box.
Your post will not be allowed if you do not type this in correctly.