New Client Welcome Form:

Current patient? Click here to fill out our Appointment Request Form.

Client Information
Name (Last Name First):
Address:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Employer:
Employer's Address:
Spouse's Name:
Is this person authorized to make medical decisions for your pet(s)?
Emergency Contact:
How did you hear about us?
If this is a Client Referral who were you referred by:
Pet Information:
Pet's Name:
Animal Type:
Sex:
Neutered/Spayed?
At what age was pet obtained?
From:
Describe your pet's diet:
List any medications your pet is currently on:
Reason for visit:
Please check any symptoms or problems you've noticed with your pet:
Appetite Loss Gagging Sneezing
Behavioral Changes Gums Bleeding Increased Thirst
Breathing Problems Limping Increased Urination
Coughing Loss of Balance Vomiting
Depression Scooting Weakness
Diarrhea Scratching Other:
Authorization
Do you give permission to release your pet's records?
I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of the animal. I also understand that ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE PERFORMED. I further agree that in case of nonpayment, any collection fees or attorney fees will be paid by me.
I AGREE TO THE ABOVE
Date:
Method of Payment: Care Credit

 

Social Security Number, Birthdate, Driver's License will be required at time of appointment.

We do everything possible to reach you quickly. If this form is submitted after hours we will contact you the morning of the next business day. If this form is submitted before the end of the day we will contact you same day before closing.

 
Walled Lake Veterinary Hospital - 1501 E West Maple Rd, Walled Lake, MI 48390-3770 - (248) 624-4829