New Pet Intake Form

Owner / Caregiver

Please provide the information below as completely as possible. All information is strictly confidential.

Owner / Caregiver

Partner / Spouse

Street Address

City

State

Zip Code

Home Phone

Cell Phone

Alternate Phone

Driver's License #

Employment

Pet Information

Pet's Name

Species

Breed

Age / Birthdate

Gender

Color / Markings

Spayed / Neutered? Yes No Unknown

Are Vaccinations Current? Yes No Unknown

Notes

Statement Of Ownership

By checking below you certify that you are the owner and or agent of the above animal and have the authorization to consent to treatment if and when it is needed.

Please bring any previous medical information, including vaccinations, with you at the time of your appointment.

Confirmation I Agree

Comments

Location

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Office Hours

Monday:

07:30 am - 06:00 pm

Tuesday:

07:30 am - 02:00 pm ~~~ 03:00 pm - 06:00 pm

Wednesday:

07:30 am - 06:00 pm

Thursday:

08:00 am - 02:00 pm

Friday:

07:30 am - 06:00 pm

Saturday:

08:00 am - 02:00 pm

Sunday:

Closed

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Testimonials

Reviews By Our Satisfied Clients

"A great place that focuses on the care of an animal. I switched from another place that charges $50.00 for a yearly checkup. Vaccines are paid for and visit is free here. That bring more people in and it serves the community as a whole. Thanks, Westchester Animal Clinic."

Tara D. - Porter, IN

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