Patient Form

* Required Field

* Owner Last Name

* Owner First Name

Cell Phone Number

* Email

Mailing Address

City

State

Zip Code

Drivers License #

License State Issued

Employer

* Emergency Contact

Alternate Phone Number

Is Your Pet On Any Medications?

Yes

If Yes, Please provide details.

* Pet's Name

Dog or Cat

Color

Breed

Age of Pet

Male or Female

Has your pet been fixed?

Microchip Number

Opt-In

By submitting this form and signing up for texts, you consent to receive marketing text messages (e.g. promos, appointment reminders) from South Seattle Veterinary Hospital at the number provided. Consent is not a condition of purchase. Msg & data rates may apply. Msg frequency varies. Unsubscribe at any time by replying STOP. Reply HELP for help or call 206-242-8338. We do not share data with third parties for marketing purposes. For more information about our privacy policy, please visit PRIVACY POLICY and TERMS & CONDITIONS.

WE DO NOT ACCEPT PERSONAL CHECKS
FULL PAYMENT IS DUE AT TIME OF SERVICE

* WA STATE requires us to report controlled substances dispensed, you may be asked to provide your drivers license or ID.