Companion Animal Wellness Center
PO Box 2847
16404 Lemolo Shore Dr.
Poulsbo, WA   98370
360-779-6534

Hours:

M,T,Th,F

8am - 6pm

W

8am - 8pm










New Client Check In

 


If you would like to make an appointment and we have never seen you before, you can assist us to expedite your check in by submitting this form.  Only use this form if you are requesting an appointment for a condition that is not of immediate concern.

If you feel that your pet's condition is an emergency, please call us directly at 360-779-6534 so we can quickly assist you.

Remember, your appointment is not confirmed until you have spoken with one of our receptionists.  Please make sure you have made contact information available for the next business day.

Looking forward to meeting you and your family.


Form - New Client

Name & Email (required)
First Name (required)
Last Name (required)
How did you hear of us? (required)
Friend's recommendation
Phone Book
Newspaper
Drove By
Other

Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
Other Phone (best one to contact you)
Phone TypePhone Number
E-Mail Address :
Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed:

Sex: (required)
Male
Female

Neutered/Spayed
Neutered
Spayed

Do you have your pets medical records?
Are the medical records kept at another veterinary Practice?
Yes
No

Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No

Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Companion Animal Wellness Center and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum.
I have read this statement and -
I Agree
I Disagree


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