New Patient Intake Form

For your convenience, we offer our client paperwork as an online form below. Feel free to complete it in advance of your appointment. We ask that you DO NOT EMAIL your pet’s medical records for privacy purposes.

New Client Form

Name(Required)







Co-Owner's Name







Address(Required)


















Name







Pet's Information

Pet's Name




Type



Sex


Altered


Is your pet current on it's Rabies Vaccine?


Do you want to add another pet?


Pet's Name




Type



Sex


Altered


Is your pet current on it's Rabies Vaccine?


How did you hear about us?






How would you like to receive reminders?



Consent
Media Release


I authorize any of my pet’s pictures taken by West Eugene Animal Hospital Staff to be used on their internet
sites (including social media) and for publicity printing purposes