New Client Form "*" indicates required fields Owner Name* Co-Owner Name Home Number Cell Number Co-Owner Cell Number Preferred Number for Contact* Email Address Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Pet Insurance Provider 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.Please list all the names and ages of your children under the age of 18NameAge Add RemovePlease list all persons over 18 years of age authorized to make treatment decisions for your pets in your absence.NameRelationshipPhone Add RemovePetsPet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or Neutered Add RemoveI 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 No Date of Appointment* MM slash DD slash YYYY 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 CreditSignature*PhoneThis field is for validation purposes and should be left unchanged.
