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New Client Registration Form

PLEASE DO NOT FILL OUT CLIENT SHEET!!! IF YOU WOULD LIKE TO BE A NEW CLIENT WE WOULD LOVE TO HAVE YOU, BUT ALL INFORMATION NEEDS TO BE FILLED OUT IN THE CLINIC!!!!

You will be asked to select a password, which must be at least 4 characters in length. Ensure this is something you will easily remember. This password will be needed to access client only areas of our site.


Client Information
Owner´s Name
Salutation
*First Name:
*Last Name:
*New Password:
*Confirm Password:
Co-owner´s Name:
Salutation:
First Name:
Last Name:
Address
*Country:
*State/Province:
*City/Town:
*Address 1:
Address 2:
*Zip/Postal Code:
*Day-Time Phone: ( ) -
*Evening Phone: ( ) -
Mobile Phone: ( ) -
*E-Mail:
*Confirm E-Mail:
Co-Owner´s Contact Information
Day-Time Phone: ( ) -
How did you find out about our practice?
Clinic Location Website Yellow Pages
Clinic Sign Newspaper Personal Referral
Other
If Other, Please Specify:
If Personal Referral, is there Someone we can Thank for this Referral?
Please use this area to give us any other relevant information about yourself or your family

  Pet Information
*Pet´s Name:
*Species:   or if other species:
Breed (If Known):
Color:
Date of Birth:
Special Identification
(Tattoo, Microchip, etc):
Sex:  
Previous Veterinary Practice (If Any):
Previous Veterinarian (If Any):
Date of Last Vaccines (if known, yyyy/mm/dd)
What Vaccines were given at this Time:
Is your Pet on any Medication or Supplement?
Yes
No
If Yes, Please List the Medication or Supplement:
What food does your pet eat?
Please type answer here:
Does your Pet have Allergies or Drug Reactions?
Yes
No
Are there any Current or Past Medical Conditions of which we should be Aware?
Yes
No
If Yes, Please Comment on the Condition(s) and Indicate if they are Current or Past Conditions:
Please use the following box to give us any other relevant information about your pet:

Please enter the validation code to the right to complete registration. [javascript must be enabled]
 

 

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September 5, 2010

       more...
    1210 North Hayden Meadows Drive
    Portland, Oregon
    97217-7558

    Phone 503-286-9155
    Fax 503-286-0430
    Wash: toll free: 360- 737-2397
    We do not utilize the appointment or prescription request function associated with this website. Please call us instead.

    GIFT CARDS AVAILABLE!!! EXAM FEE = $32.00 !

    Hours:.. M-F 8-5:00pm ( until 7:00pm Tues)....Sat. 8-2:00pm (open first , third and fifth Sat. of each month...closed second and fourth Sat). Sunday we are closed.
    Please do not email for an appointment request. We would much rather speak to you on the phone.
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