New Client

Warner West Pet Clinic

18364 Beach Blvd
Huntington Beach, CA 92648

(714)847-9617

www.warnerwestpetclinic.com

New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

New Client Warner West

Name *(required)*

First Name (required)	Last Name (required)

Address (required)
Street Address (required)

City (required) ,	State / Province (required)	Zip / Postal Code (required)

Primary Phone (required)
Phone Type	Phone Number (required)

Alternate Phone
Phone Type	Phone Number

Pet's Name

Age: Date of Birth (if known) or estimated age

Type of Pet :

Breed:

Sex:

Male
Female

Neutered/Spayed

Neutered
Spayed

Please list any additional pets here

Are your pet's vaccines current?

Yes
No
Unsure

May we request a copy of your pet's records?

Yes
No

Name of Former Veterinary Practice

Would you like us to call you to schedule an appointment?

Yes please
No thank you, I will contact you

Reasons or conditions that prompted your visit?

Special requests or conditions?

How did you find us? (required)
Referral
Drive by
Yellow Pages
Internet
Other

If Other, please specifiy:

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Warner West Pet Clinic and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Warner West Pet Clinic's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.

I have read this statement and (required)

I Agree
I Disagree

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Hours
Mon	8 - 5 PM
Tues	8 - 5 PM
Wed	8 - 5 PM
Thurs	8 - 5 PM
Friday	8 - 5 PM
Sat	8 - Noon
Sunday	Closed

Warner West Pet Clinic

(714)847-9617

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