Name *

First

Last

Profession

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Primary E-mail Address (for reminders, newsletters, Petdesk access)

Primary Contact Phone *

Cell
Work
Home

Home Phone

Work Phone

Cell Phone

Spouse/Additional Owner Name

First

Last

Profession

Spouse/Additional Owner Contact Phone

Cell
Work
Home

Home Phone

Work Phone

Cell Phone

Referred By *

(Veterinarian name, friend name or other source)

Patient Information

Patient 1

Name *

Age / Date of Birth

Sex *

Male
Female
Spayed
Neutered

Breed *

Color *

Pet Insurance Policy

Where has your pet previously received care? (Please include any specialty/referral or emergency clinics) *

If None, please insert None

Do you have a Second pet? *

Yes
No

Patient 2

Do you have a Third pet? *

Yes
No

Patient 3

Do you have a Fourth pet? *

Yes
No

Patient 4

We accept credit cards, debit cards and cash. As a pet guardian, you will be held liable for the financial responsibility of services that are performed for each pet. Unpaid balances will be recovered as deemed appropriate by Cascade Summit Animal Hospital (CSAH) management and may incur a $30.00 administration fee. A 1.5% monthly interest fee will be charged on all unpaid balances. *

I understand and abide by the above statements

For more information, please read our hospital policies here.

I acknowledge Cascade Summit does not accept personal checks *

I acknowledge

Image Consent: We often use patient pictures for our website, Facebook, and Instagram. Your signature authorizes CSAH to use photographs and videos in print media, brochures, the CSAH website, and on social media outlets. You also agree not to file any claim for revenue, or lawsuit for damages, against this veterinary practice with respect to the release of this information. *

I consent
I opt out

Holistic Medicine Consent: “I consent to the use of alternative medical therapies for my pet, including but not limited to: Acupuncture, orthopedic manipulation, herbs, homeopathy, reiki, flower essences, and nutritional supplements.” *

I accept
I opt out

Customer Pricing Notice: We have a fee of 3% on credit cards that is not greater than our cost of acceptance. This fee is not applied when using a debit card with a pin. *

I understand and abide by the above statements.

Signature *

Clear Signature

Date *

NEW CLIENT FORM

New Client/Patient Form

Patient Information

Patient 1

Patient 2

Patient 3

Patient 4

Hospital Hours

Hospital Policies