Highlands Bird & Pet Clinic

3770 NE 4th Street
Renton, WA 98056

(425)235-7387

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

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 Highlands Bird & Pet Clinic 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. Any balance that I leave unpaid will be forwarded to Highlands Bird & Pet Clinic's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.
I have read this statement and -
I Agree
I Disagree



Check the reCAPTCHA to ensure you are not a robot: