New Client and Patient Form Burien WA

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) *

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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!

Client Information

Patient Information

Medical History

To find more information, please contact us.

BURIEN VETERINARY HOSPITAL

Phone

VISIT US

Location

Hours

LOCAL RESCUES

HOSPITAL AFFILIATIONS