1824 12th Ave, Seattle, WA 98122, 206.322.5444
Your pet's well-being is our goal.

Broadway Veterinary Hospital
1824 12th Avenue
Seattle, WA 98122
(206)322-5444
email: reception@broadwayvh.com

New Client Appointment Request

If you need an urgent appointment, please DO NOT use this form. Please call 206-322-5444 to schedule your appointment.
Providing this information prior to your arrival will help us speed up your check-in process.  We look forward to meeting you and your pet.

Form - 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 (required) :
Pet's Name (required)

Age: Years, Months (required)

Type of Pet (required) :
Breed:

Markings/Coloring

Hair length: :
Sex: (required)
Male
Female

Neutered/Spayed
Neutered
Spayed

Which of the following is true of your pet? (required) :
Are there children under 7 or immunosuppressed adults in the household? (required)
yes
no

Medical records at another veterinary practice?
Yes
No

Name of Former Veterinary Practice

Phone Number of Former Clinic
Phone TypePhone Number
Reasons or conditions that prompted your visit? (required)

Special requests or conditions?

Please list any additional pets here

Time and Day Preference (required)

How did you hear about us? (required)

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 Broadway Veterinary Hospital 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 Broadway Veterinary Hospital'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


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