New Client Form in Allentown, PA | West Valley Animal Hospital

"*" indicates required fields

Owner Name*

Co-Owner Name

Pet Insurance Provider

Email Address

Address*

Street Address Address Line 2 City State ZIP Code

Home Number

Work Number

Cell Number*

Co-Owner Work Number

Co-Owner Cell Number

Name of Previous Clinic

Phone

How did you hear about us?

If a referral from an individual, please list the name for us to thank.

Occupation

Please list all the names and ages of your children under the age of 18

Name

Age

Please list all persons over 18 years of age authorized to make treatment decisions for your pets in your absence.

Name

Relationship

Phone

Pets

Pet Information

Name

Breed

Microchip#

Date of Birth

Color

Sex

Spayed or Neutered

I grant permission for West Valley Animal Hospital, LLC, its employees and agents to take and use video/audio images of my pet(s). Video/audio images include any type of recording, including but not limited to: photographs, digital images, video recordings, audio recordings or accompanying written descriptions. I agree that West Valley Animal Hospital, LLC owns the images and all rights related to them. I give permission for the images to be used in any manner, including hospital - sponsored web sites, publications, promotions, broadcasts, advertisements and posters, without prior notification. I waive any right to inspect or approve the finished images or any printed or electronic matter that may be used with them, or to be compensated for use of the images.*

Yes

Date of Appointment*

I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be due at the time services are rendered and that a deposit may be required for surgical or hospital treatment.

We accept cash, Mastercard, Visa, Discover, American Express and Care Credit

Signature*

Comments

This field is for validation purposes and should be left unchanged.

Pets

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