Owner's name *

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Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Preferred phone number *

Is this a cell phone? *

Yes
No

Alternate phone number

Email *

May we send email reminders? *

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Spouse/Partner

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Last

Phone

Emergency Contact

First

Last

Phone

Patient Information

Patient name *

Breed *

DOB *

Color or Markings *

Sex *

Male
Neutered Male
Female
Spayed Female

Previous Veterinarian *

How did you hear about Redwood Family Vet? *

Name *

Social Media Consent

I grant West Asheville Family Vet and it’s employees permission to take photographs of myself and/or my pet, and to publish those photographs for any lawful purpose, including, but not limited to, their website, social media accounts, and promotional materials, either digital or in print, in perpetuity. I also grant permission to use my name and/or my pet’s name.

Please read and sign below:

I understand that all fees are due when services are rendered. I may pay with cash, check, credit card, Care Credit or Scratchpay. There will be a service fee, in addition to any banking fees, for any returned checks. Should my account be referred to an independent collection agency, I understand that I am responsible for any additional cost such as collection fees, attorney fees and court costs. I hereby waive my rights of exemption under the law of the state of North Carolina and any other state.

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Date *

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