Coastside Veterinary Clinic, Inc. / New Client Fill in and Submit Online

Coastside Veterinary Clinic, Inc.

614 Purissima Street
Half Moon Bay, CA 94019

(650)726-9738

coastsidevet.com

New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooperation in letting us assist you.

New Client Form

Name (required)
First Name (required)
Last Name (required)
Co-Owner/Spouse

Mailing Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
E-Mail Address :
Primary (required)
Phone TypePhone Number (required)
Secondary Name
Phone TypePhone Number
Co-Owner/Spouse Number
Phone TypePhone Number
Checkbox
How did you hear about us? Google/Websearch, Yelp, HMB Review, Drive by, Facebook, Other? (required)

Whom may we thank for referring you? (Please list first and last name)

Would you like us to call you for your appointment?
Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed:

Color/Markings

Sex: (required)
Male
Female


Neutered/Spayed
Neutered
Spayed


Name of previous veterinary clinic:

May we call for a copy of the records?
Yes
No


Brief description of reasons or conditions that prompted your visit? Please also check boxes below.

Change in weight
Change in appetite/water intake
Vomiting?
Loose stool/Diarrhea
Sneezing
Fleas/Ticks
Itching/Chewing
Coughing
Shaking head/Ears
Eye discharge
Limping/Leg Weakness
Please list all current medications and/or supplements your pet is is receiving, dosing & frequency:

What do you feed your pet (brand and type), if table scraps indicate examples:

Has your pet been treated for any health problems in the past?

Has your pet ever displayed any of the following. If yes, what prompted this behavior?

Growling
Threatening displays
Bite attempts
Bites
Please list any additional pets here: (Name, Species, Age, Breed, Color, Sex, Neutered/Spayed)

Please Read
I understand that payment is required in full at the time of services, before the patient is released. We accept cash, check, Visa, MasterCard and Care Credit as forms of payment. I am the owner and/or agent of the above animal(s) and have the authorization to consent to treatment if and when it is needed. By signing this agreement, I authorize Coastside Veterinary Clinic's staff to provide care and perform and treatment, including the administration of anesthesia and surgical procedures they consider reasonable and necessary for my animal, and I consent to any such services. I understand that with any medical or surgical procedures there are always risks involved, including death, and that no warranty or guarantee is being made as to the results or cure.
I have read this statement and -
I Agree
I Disagree



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