360-694-5030 millplain@wellhavenpethealth.com

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New Client Information

Please fill out the form below as completely and accurately as possible to help us get to know you and your pet before your first visit! If you have any questions, please contact us at (360) 694-5030.

Name *

First

Last

Email *

Phone Number *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Spouse's Name

First

Last

Secondary or Spouse's Phone

How did you hear about us?

Would you like to receive email reminders? *

Yes
No

Pet's Name *

Pet's Date of Birth/Age *

Pet Species *

Dog
Cat
Exotic

Breed (if applicable)

Sex *

Male
Female
Neutered Male
Spayed Female
Unknown

Color

Current Meds

Prior Veterinarian

May we use photos of your pet for our social media pages and/or website? *

Yes, you have my permission to use my pet’s photos.
No, you do NOT have my permission to use my pet’s photos.

Add a photo of your pet to keep on file!

t

tttttttClick or drag a file to this area to upload.ttttt

Would you like to add information for another pet at this time? *

Yes
No

Pet's Name *

Pet's Date of Birth/Age *

Pet Species *

Dog
Cat
Exotic

Breed (if applicable)

Sex *

Male
Female
Neutered Male
Spayed Female
Unknown

Color

Current Meds

Prior Veterinarian

May we use photos of your pet for our social media pages and/or website? *

Yes, you have my permission to use my pet’s photos.
No, you do NOT have my permission to use my pet’s photos.

Add a photo of your pet to keep on file!

t

tttttttClick or drag a file to this area to upload.ttttt

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WellHaven Pet Health Mill Plain
906 SE 164th Ave., Suite 100
Vancouver, WA 98683
360-694-5030

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