Companion Animal Hospital Bellevue New Patient

Please only complete the following form if:

If you do not currently have a scheduled appointment, please call our front office staff

for availability and information at (425) 746-1800 PRIOR to submitting this form.   THANK YOU!

EXISTING CLIENTS updating contact information, please complete only the information that has changed.

If your name has changed, please note in the "Reason for Visit" section below the current name on the file.

OWNER'S NAME:  Last      First     Initial

ADDRESS: Street   Apt.    City   State   Zip

HOME PHONE:      WORK PHONE:

CELL PHONE:    E-MAIL:

SPOUSE/OTHER NAME

We would like the opportunity to thank the individual that referred you to our hospital.

Who referred you to Companion Animal Hospital?

Please briefly state the reason for your visit below?

When is your scheduled appointment time? 

HOW DID YOU HEAR ABOUT US?   Yellow Pages   Driving By   Website   Other

PET HEALTH HISTORY

PET NO. 1

Pet's Name:    Species: Dog  Cat     Breed:

Sex: Neutered   Male   Female   Spayed   Color:    Birthdate:

PET NO. 2

Pet's Name:    Species: Dog  Cat     Breed:

Sex: Neutered   Male   Female   Spayed   Color:    Birthdate:

PREVIOUS VETERINARIAN:

AUTHORIZATION

I assume full responsibility for all charges incurred by the care of my pet(s). 

I also understand that payment for all charges is due upon the rendering of services and

that a deposit may be required for surgical treatment or prolonged hospitalized care.

By clicking on the SUBMIT button below, I agree to all the terms and conditions

contained herein.