Edmonds Veterinary Hospital

owner Name

First NameLast Name

Pronouns

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone Number

Enter phone number

Secondary Phone Number

Enter phone number

Email*

By providing an email address, you can get 24-hour access to your pet's health information in their own private Pet Portal, shop in our online store, receive special coupons and information about special events and offers (typically 4-8/year). We do not share your information with third parties.

By providing an email address you are giving us permission to use this as a contact method. Also, you can shop on our online store, and receive special coupons and information about special events and offers via email. If you do not want to receive special offers and coupons, select “opt out” here:

Preferred method of receiving reminders:

TextEmailPostcardOpt out

Work Phone number

Enter phone number

Please indicate primary number (the one we should try to call you on first)

HomeCellWork

owner's employer/occupation

is the owner a senior citizen (over 65 years)?

YesNo

co-owner name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone Number

Enter phone number

Secondary Phone Number

Enter phone number

Work Phone Number

Enter phone number

Please list anyone authorized to give consent for care (including for emergencies, DNR & euthanasia, unless otherwise specified) of pets listed in file. Must be over 18 years of age.

So that we can collect all medical records available, please provide info of previous vet clinics - Please list the names and phone numbers (if known):

whom may we thank for their referral (if applicable)?

Eligibility for discounts (please check any that apply)

Senior (over 65)Service animalFellow VetMed

Pet's Name

breed

sex

MaleFemale

neutered/spayed

YesNo

color

date of birth

2nd pet's name

breed

sex

MaleFemale

neutered/spayed

YesNo

Color

Date of Birth

3rd pet's name

breed

sex

MaleFemale

neutered/spayed

YesNo

Color

Date of Birth

Payment Policy
Thank you for choosing us to care for your pet(s). It is our policy that payment is due at the time of service. We accept Cash, Debit, Visa, Mastercard, Discover Card, American Express and Care Credit.

By signing below you indicate that you are the owner and responsible party for services rendered for the above pets. I have read and understand the above payment policy.

Policies and Procedures

Thank you for choosing us to care for your pet(s). As a privately owned small business, each client and patient is very important to us. Our goal is to provide excellent care to each patient and excellent customer service to each client.

Please check each item to show you've read and understood*

It is our policy that payment is due at the time of service. We accept Cash, Debit, Visa, MasterCard, Discover, American Express and Care Credit. Unfortunately, we do not provide financing options. We are happy to provide an estimate of services for treatment plans.Pet insurance is not processed as human health insurance is. You understand we have no involvement in coverage, claims, or billing for insurance. If your pet has insurance, pay your bill to us in full, then file a claim with the insurance company. They will request records from us and then they will reimburse you for covered services.If for any reason there is an open invoice, a collection fee of $5.00 will accrue to the account monthly.If you need to cancel or reschedule an appointment, please notify us at least one (1) business day in advance. Proper notification whenever possible gives us the opportunity to use that time to care for another pet in need. We do implement a “no call/no show” fee of $35.00 for no show appointment and for late cancellations without reschedule.Please allow up to 48 hours to process in-house pharmacy medication refills. Alternative pharmacy refill requests may take up to 72 hours to process. Additionally, there will be an annual fee of $15 for the use of external pharmacies. This does not apply to the use of our online store pharmacy.Please treat our staff with the same respect you would expect to receive. Please always be polite and respectful to the doctors and staff. We work very hard, and we care very much. Hate speech, aggression, or discourteous behavior will result in being asked to leave and no further service. We reserve the right to refuse business to anyone.

By signing below, you indicate that you are the owner and responsible party for services rendered for the pets listed. You also indicate that you have read and accepted the policies described above.

If you would like to donate to our “Angel Fund” to help cover care costs for pets surrendered to us while they await adoption, please let your staff know today.

We encourage reviews on Google and Yelp. Positive feedback is especially valued by our team so please share your experience.

Client Information