New Client Form

Welcome to Belltowne! We are so excited to meet you and your furry friend.

Your Name (First) *

Your Name (Last) *

Co-owner Name *

Active Duty Military *

Senior Citizen (62+)? *

Primary Phone Number *

Secondary Number

Mailing Address *

City *

Zip *

Your Email *

May we send you email and text appointment reminders and clinic communication? *

Preferred Contact Method *

Text

Call

List of persons that are authorized to receive information about my pet(s): *

Payments are expected in full at time of service. Estimates can be requested at any time. By acknowledging below, I am stating that I am the owner and/or authorizing agent of the animals presented to Belltowne Veterinary Center and I am requesting veterinary services by provided. I accept full responsibility for requesting, receiving and payment services. Payment is due at the time of service: We accept VISA/Mastercard, Discover, AMEXX, Care Credit, Scratch Pay. If I miss an appointment and/or cancel less than 24 hours prior to an appointment, a deposit will be required prior to scheduling future visits. The deposit may be used toward the visit; however, if I do not keep my appointment that deposit is non-refundable.

On occasion, Belltowne Veterinary Center would like to photograph your pets fort clinic uses including but not limited to client records, website, advertising, and educational purposes etc. Do you give us permission to take pictures of your pet? *

Yes

Signature & Date *

Monday	8:00 am	6:00 pm
Tuesday	8:00 am	6:00 pm
Wednesday	8:00 am	6:00 pm
Thursday	8:00 am	6:00 pm
Friday	8:00 am	6:00 pm
Saturday	Closed
Sunday	Closed