Client Pet Information Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Todays Date *Name *FirstLastAddress Line 1 *Address Line 2City *Zipcode *County *Email *Phone Number *Additional Name on AccountAdditional Phone NumberHow do you prefer to receive vaccine reminders? *EmailMailHow do you prefer to receive appointment reminders? *EmailTextPhone CallHow did you hear about us? *Select OneSign (Drove by)Personal ReferralClinic WebsiteGoogleFacebookRochester Sports ProgramOtherPets Name *Species *CatDogBreed *Color *Date of Birth (or approximate age) *How old was your pet when you acquired them? *Gender *MaleFemaleSpayed / Neutered *YesNoIs your pet microchipped? *YesNoBrand of food being given?Is heartworm prevention being given?YesNoIf yes what is the brand of heart worm prevention?Is flea prevention being given?YesNoIf yes, what brand a flea prevention?Is your pet on medication?YesNoIf yes, please list all medications your pet is receivingList any prior illness or surgery and hear prior May we post your pet's picture on West Lake Animal Hospitals social media pages and/or website?YesNoAll payment is due at the time services are rendered. Please indicate your choice of payment below. *CashCheck (Will require a driver license number)DiscoverMC/VisaCare CreditAmerican ExpressBy checking the box below, you are agreeing that should this account be turned over to a collection agency, you will be responsible for collection fees and attorney fees where applicable *I agreeWould you like to receive marketing and promotional materials?I agree to receiving marketing and promotional materialsPlease type your name in the box below as an electronic signature: *Submit
