Online Refill Request GET DIRECTIONS 11876 SW Beaverton Hillsdale Hwy, Beaverton, OR 97005 503-646-6101

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Home » New Client Form

New Client Form

Please fill out this form before your visit.

"*" indicates required fields

Name*

First

Last

Pronouns

Additional Owner/Contact Person*

First

Last

Pronouns

Address*

Street Address

Address Line 2

City

State

ZIP Code

Primary Contact Number*

Other Phone

Email*

Your Employment

Work Phone

May we call you at work if necessary?

Yes

Co-Owner's Employment

Work Phone

May we call you at work if necessary?

Yes

We respect your privacy. Your email will be used only to contact you regarding your pets. It will not be sold or distributed. You will receive an email with login instructions for Pet Portals, our free online service allowing you to check your pet’s reminders and request refills or appointments.*

I have read and understand

How did you hear about our hospital? Please be as specific as possible. For client referrals, whom may we thank?

All professional fees are due at the time services are rendered. We will gladly prepare a cost estimate upon request (please ask the doctor or receptionist). Methods of payment include: Cash, Visa, MasterCard, American Express, Discover, Money Order, and Care Credit. As owner or agent for the pet(s) described on the following page, I certify that I have read and agree to the above financial policy, and that I am at least 18 years of age. I assume financial responsibility for all services rendered, and I understand that any accounts over 30 days past due will be subject to a monthly interest fee.*

I have read and understand

Digital Signature*

Today's Date*

MM slash DD slash YYYY

Please introduce us to your pet(s)!

Pet's Name*

Date of birth or age? Is this actual or estimated?*

Species*

Dog

Cat

Other

Breed*

Color*

Male or female?*

Male

Female

Is this pet spayed or neutered?*

Yes

Previous Veterinarian/Veterinary Hospital*

Any prior illnesses or surgeries we should know about?*

Any allergies we should know about?*

Would you like to add a second pet?*

Yes

Second Pet Information

Pet's Name*

Date of birth or age? Is this actual or estimated?*

Species*

Dog

Cat

Other

Breed*

Color*

Male or female?*

Male

Female

Is this pet spayed or neutered?*

Yes

Previous Veterinarian/Veterinary Hospital*

Any prior illnesses or surgeries we should know about?*

Any allergies we should know about?*

Would you like to add a third pet?*

Yes

Third Pet Information

Pet's Name*

Date of birth or age? Is this actual or estimated?*

Species*

Dog

Cat

Other

Breed*

Color*

Male or female?*

Male

Female

Is this pet spayed or neutered?*

Yes

Previous Veterinarian/Veterinary Hospital*

Any prior illnesses or surgeries we should know about?*

Any allergies we should know about?*

Would you like to add a fourth pet?*

Yes

Fourth Pet Information

Pet's Name*

Date of birth or age? Is this actual or estimated?*

Species*

Dog

Cat

Other

Breed*

Color*

Male or female?*

Male

Female

Is this pet spayed or neutered?*

Yes

Previous Veterinarian/Veterinary Hospital*

Any prior illnesses or surgeries we should know about?*

Any allergies we should know about?*

Client Signature

Signature*

Date*

MM slash DD slash YYYY

CAPTCHA

Phone

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

Make Appointment

Services

Pet Records

Meet the Team

What's Next

1
Call us or schedule an appointment online.
2
Meet with a doctor for an initial exam.
3
Put a plan together for your pet.

Make An Appointment

Where family pets find loving care

Make An Appointment

Beaverton Pet Clinic

11876 SW Beaverton Hillsdale Hwy,
Beaverton, OR 97005

Call 503-646-6101
Text 503-646-6101
Email [email protected]

Emergencies

During operating hours, call us at 503-646-6101.

For emergencies outside of business hours, please call Dove Lewis Emergency Animal Hospital at 503-228-7281.

Monday

8:00am - 6:00pm

Tuesday

8:00am - 6:00pm

Wednesday

8:00am - 6:00pm

Thursday

8:00am - 6:00pm

Friday

8:00am - 6:00pm

Saturday

8:00am - 5:00pm

Sunday

Closed

New Client Form

Please introduce us to your pet(s)!

Second Pet Information

Third Pet Information

Fourth Pet Information

Client Signature

What's Next

Call us or schedule an appointment online.

Meet with a doctor for an initial exam.

Put a plan together for your pet.

Where family pets find loving care

Beaverton Pet Clinic

Emergencies