541-672-1621
parkwayreception@gmail.com
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Now accepting new clients
Online Forms
New Client Form
Please fill out this form as completely and accurately as possible so we can get to know you
and your pet(s) before your visit.
Name
(Required)
First
Last
Street Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Mailing Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Cell Phone
(Required)
Home Phone
Work Phone
Drivers License
State
Email
(Required)
Employer
Employer's Phone
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Other Responsible Party
Name
(Required)
First
Last
Street Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Cell Phone
(Required)
Home Phone
Work Phone
Drivers License
State
Employer
Employer's Phone
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Emergency Contact
(Not the same as above)
Name
(Required)
First
Last
Phone
Relationship
Professional fees are due when services are rendered, or products are picked up. We accept cash, checks, VISA, Master Card, Discover and Care Credit. I understand that I assume responsibility for all charges, past and present, incurred in the care of my animals) and they will be paid at the time of release. I also understand that a deposit may be required for surgical treatment or hospitalization. Accounts sent to collections will be inactivated and no future service will be provided. There is a return check fee of $35.
(Required)
I have read and accept
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
Pet's Name
(Required)
Species (dog, cat, etc.)
(Required)
Age/Date of Birth
(Required)
Breed
(Required)
Sex
(Required)
Male
Male Neutered
Female
Female Spayed
Do you have a second pet?
(Required)
Yes
No
Pet's Name
(Required)
Species (dog, cat, etc.)
(Required)
Age/Date of Birth
(Required)
Breed
(Required)
Sex
(Required)
Male
Male Neutered
Female
Female Spayed
Do you have a third pet?
(Required)
Yes
No
Pet's Name
(Required)
Species (dog, cat, etc.)
(Required)
Age/Date of Birth
(Required)
Breed
(Required)
Sex
(Required)
Male
Male Neutered
Female
Female Spayed
Policies
Please read through our current hospital policies and accept
No Abuse
(Required)
We will not tolerate any verbal or physical abuse towards any member of our team. Any client in breach of this policy will be asked to seek veterinary care elsewhere.
Photograph
(Required)
I agree Parkway Animal Hospital may take pictures and videos of my pet for continuing education, medical publications, promotion, social media, etc. These images will have no identifying information about me or my family associated with them. They may contain my pet's name. I will claim no ownership of or authority over said images.
No Shows & Late Cancellation Fees
(Required)
I understand that Parkway Animal hospital requires a 24-hour advanced notice for changes in your scheduled exam. With the 1st missed appointment, our staff will call to ensure the well-being of you and your pet, in addition to rescheduling your exam. Additional missed exams and late cancellations may result in a $50.00 fee or upfront payment of exam fees.
Emergency and After Hours
(Required)
Parkway Animal Hospital provides consultation and or care for our current clients. If we have not seen the patient or your family has not visited the clinic within the last 3 years, an emergency client reinstatement fee will apply.
How did you hear about us?
Phone book
Online
AAHA Referral
Hospital Sign Referral
Other
Other
Name
This field is for validation purposes and should be left unchanged.
