WEA Animal Hospital

3613 South 18th Street, Suite A
Lafayette, IN 47909

(765)838-0954

www.weaanimalhospital.com

New Client Form

 

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooperation in letting us assist you.

 

​Due to the abundance of new clients not showing to their appointments
and negatively affecting our ability to help other clients and their pets:

We now require payment of a NON-REFUNDABLE $100.00 Appointment Reservation Fee
​before scheduling a new client appointment.

 

This payment will be applied to services rendered during the first visit when the appointment is kept.
If the appointment is not kept, it will not be rescheduled, nor will the fee be returned.

 

The payment will NOT BE REFUNDED if the appointment is not kept.

 

Upon completion and submittal of this form, a member of our staff will contact you
within 2 business days to collect the reservation fee and schedule an appointment.

 

Currently, our earliest appointment openings are 3-4 weeks away.

New Client

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,		State / Province (required)
Zip / Postal Code (required)
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed:

Sex: (required)

Male
Female


Neutered/Spayed

Neutered
Spayed


Are your pets vaccines current?
Do you have pets medical records?
Medical records at another veterinary Practice?

Yes
No


Name of Former Veterinary Practice

May we request a transfer of records?

Yes
No


Would you like us to call you for your appointment
Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here


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