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.

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New Client Form

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Name *

Partner or other responsible party

Preferred Pronoun

He/Him
She/Her
They/Their
Prefer Not To Answer

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

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Home Phone *

Work Phone

Cell Phone

How Did You Hear About Us? *

Internet
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Drive By
Referral

Name of person or business who referred you *

How would you like your reminders sent? *

Snail Mail
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Phone

How would you like your financial records sent? *

Snail Mail
Email
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Phone

How would you like your general communications sent?* *

Snail Mail
Email
Text
Phone

Patient Information

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Patient Name *

Canine / Feline / Other *

Please Check

Male
Female
Neutered Male
Spayed Female

Breed

Age

Color

May we request records from your regular or previous veterinarian?

Name of Veterinary Clinic

Patient Information

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Patient Name *

Canine / Feline / Other *

Please Check

Male
Female
Neutered Male
Spayed Female

Breed

Age

Color

Names of Other Pets In Home

May we request records from your regular or previous veterinarian?

Name of Veterinary Clinic

Preferred Method of Payment

Payment is due at the time of service.

Social Media Consent

Yes, you can post my pet on social media
No, please don't post my pet on social media

Please let us know if we have your consent to post a photo of your pet on social media.

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Ready to Visit East Bend Animal Hospital?

We would love to hear from you! Click on the button to book your appointment, or call us at 541-318-0090.

Book Appointment

Location

409 NE Greenwood Ave Suite 110
Bend, Oregon 97701

Contact Information

Phone: 541-318-0090
Email: ebah@eastbendvet.com

Hours

Monday – Friday: 8 AM – 6 PM
Saturday: 9 AM – 4 PM
Sunday: Closed

Have a Question?

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