Animal Doctor Westside Your Other Family Doctor Welcome Sheet Welcome Sheet - ADW First Name * Last Name * Address * Apartment # City, State * Zip Code * Email * Home Phone * Work Phone Spouse/Co-Owner Name Spouse/Co-Owner Phone Emergency Contact Name * Emergency Contact Phone * How did you hear of our clinic? * Select from list Recommendation Google Facebook Yelp Drive-By Other If recommended, by whom? Name of Pet #1 * Species * Select from list Dog Cat Other Breed * Color * Birthdate * Sex * Select from list Male Male Neutered Female Female Spayed Name of Pet #2 Species Species Dog Cat Other Breed Color Birthdate Sex Select from list Male Male Neutered Female Female Spayed Name of Pet #3 Species Select from list Dog Cat Other Breed Color Birthdate Sex Select from list Male Male Neutered Female Female Spayed Additional pet(s) not listed, including species, breed, color, birthdate, and sex. By selecting yes, you authorize veterinary hospital listed to release requested medical information for your pet(s) to Animal Doctor. Animal Doctor has reserved the right to request medical records on owner's behalf. * Yes No Previous Veterinary Hospital City/State I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment. * Type name to sign Date * Submit If you are human, leave this field blank.