Please choose a location*

Kirkland
Newcastle/Renton

Owner Information

Name*

First Last

Preferred Pronouns

Spouse/Partner*

First Last

Spouse/Partner Preferred Pronouns

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone*

Cell Phone

Work Phone

Email*

Employer Name

Spouse/Partner Cell Phone

Spouse/Partner Work Phone

Spouse/Partner E-mail

Spouse/Partner Employer

How did you hear about us?*

Sign/Drive By
Internet Search
Referred
Other

What did you search?

Referred by

If other

Do you prefer to receive reminders when your pet is due for vaccines via*

Email
Postcard

Pet Information

#1 Pet’s name*

Species*

Cat
Dog
Other

If Other

Date of Birth*

Sex*

Male
Neutered
Female
Spayed

Breed*

Color*

Weight

Please list ALL veterinary hospitals your pet has been to. Please include Hospital name, phone #, and the name the account is under.

Medical Problems Diagnosed in Past

#2 Pet’s name

Species

Cat
Dog
Other

If Other

Date of Birth

Sex

Male
Neutered
Female
Spayed

Breed

Color

Weight

Please list ALL veterinary hospitals your pet has been to. Please include Hospital name, phone #, and the name the account is under.

Medical Problems Diagnosed in Past

Can Eastside Veterinary Associates publish your pet’s photo or likeness with first name only in print and digital materials or online?*

Yes
No

Authorization

I hereby authorize the veterinarians of Eastside Veterinary Associates to examine, prescribe for, and treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I understand these charges must be paid at the time services are rendered and that a deposit is required for surgical treatment. I understand that a broken appointment fee will be assessed for missed appointments or appointments that are canceled or rescheduled with less than 24 hours notice.

Signature of Owner/Agent*

First Last

Date*

Welcome!

Owner Information

Pet Information

Authorization