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Annual Client Form & Hospital Policies
We ask that this form be updated annually to keep our records current.
Owners Name
*
First
Last
Primary Email
*
Primary Phone Number
*
Phone Type
*
Cell
Work
Home
Address
*
Street Address
Address Line 2
City
State & County
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Secondary Owner
Secondary Owners Name
First
Last
Secondary Email
Phone Number
Phone Type
Cell
Work
Home
Pet Information
Pet's Name
For new clients - How did you hear about us?
For existing clients - Have you gained or lost any furry family members?
*
Do your pet's have a Wellness Plan?
*
Yes
No
I'd like more information
Do your pet's have Pet Insurance for accident/injury/illness?
*
Yes
No
I'd like more information
If YES, which Insurance provider do you have?
Hospital Policies
Our Appointment Policy
Please arrive on time for your scheduled appointment. Late arrivals cause schedule delays for those patients who arrive promptly at their appointment time. Late arrivals will be worked into the schedule if time allows, a Late Appointment fee may be charged. If you are significantly delayed, you may be asked to reschedule your appointment to another day or on a walk-in basis.
Cancellation Policy/No-Show Policy
We understand there may be times when you miss an appointment due to emergencies or obligations with work or family. Nevertheless, we encourage you to call at least 24 hours before your appointment to cancel. EACH TIME A PATIENT MISSES AN APPOINTMENT WITHOUT PROPER NOTICE, ANOTHER IS PREVENTED FROM RECEIVING CARE. Therefore, EAST-WEST ANIMAL HOSPITAL reserves the right to charge a fee of $72.00 for a missed appointment without prior notice of 24 hours. This fee will be payable by statement or at your next scheduled visit.
This also applies to appointments being rescheduled 3 or more times.
Appointments for specialty services may require payment before scheduled service.
As a courtesy, we agree to confirm your appointment to your primary phone number from one to three days before your scheduled appointment. When you give us a 24 hour notice, your reserved time can be made available to another patient. Thank you for understanding the value of our cancellation policy and forms fee policy to each of our patients.
Payment Policy
We will gladly prepare a written treatment plan of services. All professional fees are due at the time of services are rendered. In cases of extreme medical or surgical procedures where payment in full may be difficult at discharge, we accept major credit cards, or can establish a payment arrangement through CareCredit or ScratchPay in advance of treatment.
Consent
*
By submitting this form, you agree to abide by the appointment, cancellation, and payment policies.
Please Acknowledge With Full Name
*
First
Last
Today's Date
*
Date Format: MM slash DD slash YYYY
Δ
Home
About
Fear Free
Our Veterinarians
Our Care Team
Careers At EWAH
Employment Form
Services
Acupunture & TCVM
Behavior Services
Dental Care
Laboratory & Diagnostics
Microchipping
Personalized Vaccine Care
Stance Analysis
Summus Laser Therapy
Surgery Services
Ultrasound, Echo & Endoscopy
Wellness & Prevention Plans
Client & Patient Center
Client Center
Annual Client Form & Hospital Policies
Procedure Anesthesia & Medical Authorization Release
Pet & Pet Parent Social Media Agreement
Payment Options
Patient Center
Pet Information
Pre-Visit Questionnaire
Behavior Questionnaires
Pet Health
Pet Health Library
How-To Videos
Pet Health Checker
Pet Food Recalls
Product Recalls
Pet Insurance
News
East-West Blog
Promotions
Contact
Online Store
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