 info@bayviewanimalhosp.com … 585-671-3120 … …

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Client/Patient Information Form

Name: Bayview Animal Hospital
Address: 1217 Bay Road, Suite 1A, Webster, NY, 14580, United States
Telephone: 585-671-3120
Price range: $

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Client/Patient Information Form

Please complete our Client/Patient Form. All fields marked with * are required and must be filled.

Owner's Name *

First

Last

Co-Owner's Name

First

Last

Primary Owner Cell *

Co-Owner Cell

Primary Owner Home Phone

Co-Owner's Home Phone

Primary Owner Work Phone

Co-Owner's Work Phone

Primary Owner Email *

Co-Owner's Email

Address *

Address Line 1

Address Line 2

City

State

Zip Code

How would you prefer we contact you?

Email
Phone

What is the best number to reach you? *

The following individual(s) is designated as alternate to give consent for services in my absence. The designation remains in place until the hospital is otherwise notified. As the owner, you are still responsible for any charges incurred by the consent given by the alternate individual.

Name

First

Last

Phone

Have you been to a veterinarian before?

Yes
No

If yes, who?

How did you become aware of our hospital?

NOTE: For the safety of all animals here, it is our policy that all animals be up to date with their vaccinations in order to be hospitalized or boarded.

Patient 1:

Pet Name *

Species *

Breed *

Color *

Sex *

Male
Female

Spayed/Neutered? *

Yes
No
Unsure

DOB or Approximate Age *

Add another pet? *

Yes
No

Patient 2:

Pet 2 Name *

Species *

Breed *

Color *

Sex *

Male
Female

Spayed/Neutered? *

Yes
No
Unsure

DOB or Approximate Age *

Add another pet? *

Yes
No

Patient 3:

Pet 3 Name *

Species *

Breed *

Color *

Sex *

Male
Female

Spayed/Neutered? *

Yes
No
Unsure

DOB or Approximate Age *

Add another pet? *

Yes
No

Patient 4:

Pet 4 Name *

Species *

Breed *

Color *

Sex *

Male
Female

Spayed/Neutered? *

Yes
No
Unsure

DOB or Approximate Age *

I, the undersigned, am at least 18 years of age and hereby state that I am the owner/caregiver of the above-specified animals.

I hereby give consent for the use of any images of my pet, taken by Bayview Animal Hospital, in any and all marketing materials, including, but not limited to: the website, social media accounts and digital/print promotional materials. *

Yes
No

ALL FEES ARE REQUIRED TO BE PAID IN FULL UPON COMPLETION OF THE VISIT. In the event any balance due hereunder is not paid as agreed, the undersigned jointly and severally agree to pay all costs included in said unpaid balance, including a reasonable collection and/or attorney's fees.

Please upload previous medical records and vaccine history:

Click or drag a file to this area to upload.

Signature *

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Your preferred Webster veterinary hospital.

Our veterinarians and staff have a long tradition of community service. Animals, medicine and science are our passions and we are devoted to treating every animal and owner as a trusted friend. We serve the communities of Webster & Penfield.

Contact

P: (585) 671-3120
E: info@bayviewanimalhosp.com

Hours

Monday and Wednesday: 8 a.m. – 7 p.m.
Tuesday and Thursday: 8 a.m. – 5 p.m.
Sat: 8 a.m. – 2 p.m.
Sun: Closed

Location

1217 Bay Road, Suite 1A
Webster, NY 14580

Have a question?

Get in touch! Complete the form below if you have any non-medical questions and our team will be in touch. If you’re in need of immediate assistance or would like to make an appointment, please contact us at 585-671-3120 or fill out an appointment request form.

Name *

First

Last

Email *

Phone

How can we help you? *

Email

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