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Holistic Care
About
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Emergency
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503-655-1722 22320 Salamo RoadWest Linn,
OR 97068

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22320 Salamo Rd,
West Linn, OR 97068

Call / Text: 503-655-1722

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Home » New Client Form

New Client Form

You can submit our “New Client Form” in two ways:

1) Fill out and print our New Client Form here. You must bring the form printed and filled out on your next visit.

2) Fill out our form online:

"*" indicates required fields

Name*

First Last

Profession:*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

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

Primary Contact Phone:*

Cell

Work

Home

Cell Phone

Work Phone

Home Phone

Spouse/Additional Owner Name:

Profession

Spouse/Additional Owner Contact Phone:

Cell

Work

Home

Cell Phone

Work Phone

Home Phone

Referred By:*

Location

Website

Google

Yelp

Veterinarian

Friend

Other

(Veterinarian name, friend name or other source)

PATIENT INFORMATION

PATIENT 1

Pet Name*

Age/Birthdate:*

Sex:*

Male

Female

Spayed/Neutered:*

YES

NO

Breed:*

Color:*

Pet Insurance Policy:

PATIENT 2

Would you like to add a second pet?

YES

NO

Pet name - Patient 2

Age/Birthdate

Sex

Male

Female

Spayed/Neutered

YES

NO

Breed:

Color:

Pet Insurance Policy:

PATIENT 3

Would you like to add a third patient?

YES

NO

Pet Name

Age/Birthdate:

Sex

Male

Female

Spay / Neutered

YES

NO

Breed

Color

Pet Insurance Policy:

PATIENT 4

Would you like to add a fourth patient?

Yes

No

Pet Name:

Age/Birthdate:

Sex

Male

Female

Spayed/Neutered:

YES

NO

Breed:

Color:

Pet Insurance Policy:

We accept credit cards, debit cards and cash. Please visit our website (www.cascadesummitvets.com) for details on all of our hospital policies. 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

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.

Entering Your Full Name Here Will Serve As Your Digital Signature:*

Date*

MM slash DD slash YYYY

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

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Cascade Summit Animal Hospital © 2020
22320 Salamo Road, West Linn OR 97068

Call or Text 503-655-1722

HOSPITAL AFFILIATIONS

Oregon Veterinary Medical Association

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OFFICE HOURS

Monday – Friday:
8:00am – 6:00pm

Saturday – Sunday:
Closed