New Client Information Sheet


Welcome to:
Westonka Animal Hospital and Laser Surgery Center
4861 Shoreline Drive; Mound, MN 55364
Phone: 952-472-4900

Since this form is submitted via email and we only we check emails once daily, if your appointment is more than 1 business day from now, feel free to complete and submit this form via the internet. However, if your appointment is less than 1 business day from now, please complete, print at home, and bring to the clinic with you. Thanks.

I have an appointment on (date)
Your Name:
Your spouse's name:
Address:
City:
Zip Code:
Home Phone:
Work Phone:
Cell Phone:
Your Driver's License #:

Email Address:         
-If you would like to periodically receive information regarding our clinic via email. Your information will be kept confidential.
Place of Employment:
City:


First Pet Information
Name:   Breed:
Date of Birth:Color:
Gender:
Unique Traits or Talents:

Second Pet Information
Name:   Breed:
Date of Birth:Color:
Gender
Unique Traits or Talents:

Third Pet Information
Name:   Breed:
Date of Birth:Color:
Gender:
Unique Traits or Talents:

Whom May We Thank?
I Became Aware of Your Hospital From:
I know one of your staff members:  name of employee to thank
Friend or Family member referred me:  name of friend or family to thank
My regular veterinary clinic referred me  (name of clinic to thank) and I plan to return to them as a client.
Other:  name to thank

ALL FEES ARE DUE WHEN SERVICES ARE RENDERED. WE ACCEPT CASH, CHECKS, VISA, MASTERCARD, DISCOVER, VPI Veterinary Pet Insurance, & CARE CREDIT.
Which do you payment option will you be using at your initial visit?

Again, thank you for giving us the opportunity to serve you.

May we contact your previous hospital to obtain medical records? Yes
No
If "Yes":
Name of previous veterinary hospital: (if not a referral from above listed hospital)
Phone number (if known):

    Or Use Your Browser's Print Function To Print Out This Information Sheet.

    So that you get to know us better before your first visit, our entire staff is committed to the following Core Values:
  1. in celebrating the love people have for their pets
  2. the care we want = the care patients want
  3. patients' interests come first, community interests second, client's interests are third, our's are fourth.
  4. self improvement = care improvement
  5. that we will not participate in unreasonable euthanasias*
  6. in diagnosing before treating
*For example, we will not euthanize for behavior problems unless that pet has completed and failed a behaviorial modification program directed by a veterinarian. Even then, we may chose to help that pet find a new home which may be a better fit for that pet rather than to euthanize it.

For Office Staff:   [   ] WC Sent        [   ] Hx Entered

For printable driving directions to our clinic, go to our Directions page at http://www.westonkaanimalhospital.com/directns.html
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