New Patient Form 1. Please download, print, and fill out this form to bring with you to your appointment. -OR- 2. Fill out online below.Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Phone Number* I prefer email / phone communicaon for lab results (select one)* Email Phone How did you hear about us? Google Search Facebook Instagram Print Ad Friend/Family Event Pet Name* Breed Color Pet GenderMaleFemaleDate of birth or approximate age Neuter/Spayed? Yes No Unknown Is he/she microchipped? Yes No Unknown If Yes, what is the microchip number? Add another pet? Yes No Pet Name* Breed Color Date of birth or approximate age Neuter/Spayed? Yes No Unknown Is he/she microchipped? Yes No Unknown If Yes, what is the microchip number? Previous Veterinarian Name Previous Veterinarian PhonePrevious Veterinarian Location City State / Province / Region May we contact your previous veterinarian to obtain your pet’s medical records? Yes No Please send us any previous medical records for your pet prior to the appointment. It is important that we have those records so that the doctor and technicians are able to give your pet the best of care. Upon request, Woodinville Veterinary Hospital will gladly prepare a written estimates for any treatment plan your pet may need during their visit with us. This is important for you to read and sign as ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. In the case of extensive medical or surgical procedures, we understand full payment may be difficult. In these cases, we accept most major credit cards, Care Credit and ScratchPay. Applied fees will be reimbursed by the pet insurance company to you, directly, if your pet is covered. Please note there is a $25.00 service charge for any check returned unpaid. We do not extend credit. To prevent the spread of infectious diseases, all hospitalized and boarding animals must be current on their yearly exams, all vaccines or titer tests and be free from internal and external parasites. The signature below authorizes this level of care and the appropriate charges will be assessed in the discharge invoice. If you have any questions, please feel free to reach out to us! Once we receive all of this information we can set up a visit for you! Signature Δ
