New Client and
Patient Form
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Please fill out the new client and patient form.

CLIENT INFORMATION

Last Name:*
First Name:*
Spouse:
Address*
City:
State:
Zip:
Home Phone
E-mail *
Work Phone
Spouse Work Phone
Cell Phone*
Spouse Cell Phone
Emergency Contact
Phone

PATIENT INFORMATION

Name:
Sex:
Animal Breed


Reason for visit:

MEDICAL HISTORY

Heartworm Test – Date
Results
FELV/FIV Test
Results
Flea Control Product
Any known medical history:
Payment is expected at the time of service.  We honor cash, check, Visa, Mastercard, Discover and Care-Credit.  In order to avoid misunderstandings, we urge all charges be discussed with the doctor before services are performed. I agree. *
I understand the terms of payments and agree to pay when treatment/services are rendered. (Please initial below) *
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BURIEN VETERINARY HOSPITAL

At Burien Veterinary Hospital, we serve pets and their guardians in Burien, White Center, Tukwila, Des Moines and the surrounding areas.
Phone
(206) 242-1290

VISIT US

Location
14628 Ambaum Blvd SW, Seattle, WA 98166
Hours
Monday - Friday : 9am - 6pm
Saturday : 9am - 12pm
Sunday : Closed

LOCAL RESCUES

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HOSPITAL AFFILIATIONS

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