New Client

Veterinary Associates of Westville

New Client Check In

If you have make an appointment, you can assist us to expedite your check in by submitting this form.

Form - New Client

Name & Email (required)
First Name (required)	Last Name (required)

Address (required)
Street Address (required)


City (required)	State/Province (required)	Zip/Postal Code (required)
,

Daytime Phone (required)
Phone Type	Phone Number (required)

Cell Phone (required)
Phone Type	Phone Number (required)

E-Mail Address :

Pet's Name (required)

Age: Years, Months (required)

Type of Pet (required) :

Breed: (required)

Sex: (required)
Male
Female

Neutered/Spayed (required)
Neutered
Spayed

Are your pets vaccines current?

Do you have pets medical records?

Medical records at another veterinary Practice?
Yes
No

Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No

Would you like us to call you for your appointment

Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

Please Read
I hereby authorize the veterinarian to examine and treat the above-described pet.I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Veterinary Associates of Westville and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Veterinary Associates of Westville's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.

I have read this statement and -
I Agree
I Disagree

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