Pet Details

Pet Name(Required)

Name

Breed

Species

Color

Sex(Required)

Male

Female

Male Neutered

Female Spayed

Weight

Pet’s Age or Approximate Birthdate(Required)

Date of your pet's appointment(Required)

Owner Details

Name(Required)

First Last

Address

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

Primary Phone Number(Required)

Is this a cell phone? May we text you?(Required)

Yes

Secondary Phone Number

Is this a cell phone? May we text you?

Yes

Name of Co-Owner/Spouse/Person authorized to make medical decisions for your pet

First Last

Co-Owner/Spouse/Authorized Person's phone number:

Co-Owner/Spouse/Authorized Person's email address:

What are your preferred ways to be contacted? Check all that apply.

Phone Call

Text Message

Standard mail (for health service reminders only)

How did you hear about us?

Personal referral

Drive by / Live or work in neighborhood

Web / Google

Yelp

Other

Previous Veterinary Clinic(Required)

May we contact them for your pet's previous medical records?

Yes

N/A - I do not have a previous vet

We love taking photos of cute pets! May we take photos of your pet(s) and share them on our public social media pages? (Facebook, Instagram, Website, print material, etc.) Photographs may be accompanied by your pet's name only. Owner's personal information will NOT be shared. *(Required)

Yes - I opt in. You may use my pet's photograph for social media and marketing.

No I opt out. Please do not use photos of my pet for social media or marketing.

Financial Policy

PAYMENTS:
*** PAYMENT IS DUE AT THE TIME OF SERVICE FOR ALL PURCHASES, SERVICES AND TREATMENTS.

We accept cash, checks (established clients only), Debit, Visa, MC, AMEX and Discover.

We DO NOT extend credit or offer billing or in-house payment plans.

We DO accept third-party financing and payment options through CareCredit and ScratchPay.

Pre-qualification/Application is required for these financing options.

Please visit their websites or inquire with our staff PRIOR to treatment, for details.

DEPOSITS:

New client visits require a deposit of $100 to hold your appointment.

Dental, surgical, and anesthetic procedures require a $200 deposit to be paid at time of scheduling.

Ultrasound/Echocardiogram procedures require full pre-payment at time of scheduling.

Surgical and hospitalization services may require full or partial payment based upon the estimated treatment plan cost at the time of admission/hospitalization.

*(Required)

I have read and understand the NSVC Financial Policy

Cancellation, Late & Missed Appointment Policy

CANCELLATIONS:
If you are not able to keep an appointment, we ask that you call us promptly so we may offer that appointment to another patient in need.

MISSED APPOINTMENTS: Failure to be present at the time of a scheduled Exam or Surgical/Dental appointment will be recorded as a missed appointment on your account and fees may apply.

LATE APPOINTMENTS:
Exam appointments that are 10 or more minutes late for check-in will be required to reschedule; fees may apply.

EXAM APPOINTMENTS:

4 hours' advanced notice is required to change or cancel your appointment to avoid fees.

Missed or late cancelled appointments will incur a $93 fee.

DENTAL/SURGICAL APPOINTMENTS:

Dental/Surgical appointments must be cancelled by 9am, 48 hours prior to the date of the procedure to avoid cancellation fees.

Missed and late-cancelled Dental/Surgical appointments will forfeit their pre-paid deposit of $200.

We understand there are times when emergency situations present themselves that are beyond your control. We will do our best to work with you to reschedule without an applicable fee when possible.

*(Required)

I have read and understand the NSVC Cancellation, Late and Missed Appointment Policies.

Consent for Release of Records

Your pet's physical medical records are the property of North Seattle Veterinary Clinic. The information contained within the records about your pet are the property of the pet's owner. By law, we have 10 days to supply your pet's medical records to you at your request. From time to time, we may be asked to send your pet's records to third parties, such as other veterinary clinics, emergency clinics, specialists, groomers, or boarding facilities. By default, we will not give information out unless your pet is being seen as an emergency and it is critical for your pet's health or if we are referring your pet directly to a Specialist.

(Required)

Opt IN - Yes, please release my pet's records and vaccine/medical history to third party entities.

Opt OUT - No, please only send records to me and I will distribute the inquiring third party entities.

I have read and understand the information and policies above. I agree to comply with the terms and conditions therein. Please sign below.(Required)

New Client Form

Please Note:

Pet Details

Owner Details

Financial Policy

Cancellation, Late & Missed Appointment Policy

Consent for Release of Records

Why Choose Us

Request a Refill

Schedule a Visit

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