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New Client and
Patient Form
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, and Discover.  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) *
Submit Form

To find more information, please contact us.

Burien Veterinary Hospital is an excellent place to grow your career in veterinary medicine. Be part of our wonderful team!
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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, Burien, WA 98166
Hours
Monday - Friday : 9am - 6pm
Saturday & Sunday: Closed

LOCAL RESCUES

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HOSPITAL AFFILIATIONS

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