Highlands Bird & Pet Clinic

3770 NE 4th Street
Renton, WA 98056

(425)235-7387

www.highlandsbpclinic.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 cooporation in letting us assist you.

New Client

Name (required)
First Name (required)
Last Name (required)
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)
E-Mail Address :
Pet's Name (required)

Birthdate (Age in Years/ Months if birthdate unknown) (required)

Type of Pet (required) :
Breed:

Sex: (required)
Male
Female
Unknown


Neutered/Spayed (required)
Neutered
Spayed
Unaltered


Are your pet's vaccines current?
Do you have your pet's medical records?
Medical Records at another veterinary practice?
Yes
No


Name of Former Veterinary Practice

Reasons or conditions that prompted your visit?

Would you like us to call you to set up an appointment? (required)
Yes
No


Special requests or conditions?

Please list any additional pets here


Check the reCAPTCHA to ensure you are not a robot: