BETTER PET HEALTHCARE New Client Registration Step 1 of 5 0% This form is for new clients. It is designed to help streamline the registration process. If you are an existing client, you do not need to fill out this form. Attention: new clients are required to put down a non-refundable deposit, equal to the cost of an examination, at the time of appointment scheduling. This deposit will be applied toward the invoice. Should the client fail to show up for the appointment without sufficient notice to cancel, the client will forfeit this deposit.Your Name* First Last Spouse/Co-Owner First Last Your Date of Birth* MM slash DD slash YYYY Your Driver's LIcense* Your Phone Number*(###) ###-####Alternative PhonePlace of Employment Business/Organization NameEmployer's Name First Last Employer's Phone(###) ###-####Your Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this also your mailing address?* Yes No Your Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your Email Address Enter Email Confirm Email How would you like to receive reminders?* Postcard Email How did you hear about us?* Friend/Family Website Facebook Instagram Radio Your Pet's Details*Pet NameDate of BirthMale or FemaleSpayed or Neutered?SpeciesBreedColors/Markings To add another pet, click the small plus icon on the right side. Spay = Female Neuter = Male Species Example: Dog, cat, bird, etc. Breed Example: Golden retriever, siamese, etc. Agreement I authorize the veterinarians at Countryside Veterinary Clinic to examine, prescribe for, and/or treat the above described pet(s). I assume responsibility for all charges incurred in the care of described pet(s). Countryside Veterinary Clinic requires payment in full at time of service. Method of Payment* Cash MC/Visa CareCredit Signature of Owner/Agent* Date* MM slash DD slash YYYY Financial Policy Welcome to Countryside Small Animal Veterinary Clinic. We are committed to providing your pet with the best possible care. It is our goal for clients to clearly understand their pets' needs, as well as their financial responsibility before treatment begins. Therefore, we offer the following financial arrangements: 1. Cash 2. Visa or MasterCard 3. Debit Card with Visa or MasterCard logo 4. CareCredit: For animals requiring extensive treatment, payment arrangements may, if approved, be made through CareCredit, a finance company for veterinary and medical expenses. WE NO LONGER ACCEPT PERSONAL CHECKS FOR AFTER HOURS EMERGENCY CARE. • Any person bringing in an animal owned by another person is considered to be financially responsible for said animal. I agree to pay all costs and expenses incurred should this account be turned over to an attorney, collection agency, or any action through the legal system for collection, including attorney fees, collection fees, court costs, and interest. Signature* Date* MM slash DD slash YYYY Have you already scheduled an appointment?* No Yes What day is your appointment?* MM slash DD slash YYYY This is so we can confirm your schedule on our end. What time is your appointment?*8:00 AM8: 30 AM9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM1:00 PM1:30 PM2:00 PM2:30 PM3:00 PM3:30 PM4:00 PM4:30 PM5:00 PMThis is so we can confirm your schedule on our end. Appointment Terms* I agree to the appointment policyAttention: new clients are required to put down a non-refundable deposit, equal to the cost of an examination, at the time of appointment scheduling. This deposit will be applied toward the invoice. Should the client fail to show up for the appointment without sufficient notice to cancel, the client will forfeit this deposit.Thank you for taking the time to fill out our new client registration form. Upon submission, we will call you to schedule your appointment and handle your deposit within 24 hours.CAPTCHAForm Spam ProtectionNameThis field is for validation purposes and should be left unchanged. Δ New Patient Client Portal Request Appointment Prescription Refill Food Pickup Resources ABOUT US HOURS Monday – Friday: 7:30 AM – 5:30 PMSaturday – Sunday: Closed CONTACT Clinic: (509) 663-6542After Hours Emergency: (509) 776-7834 Countryside Veterinary Clinic is a state-of-the-art animal hospital located in Wenatchee, Washington. We proudly serve Wenatchee, East Wenatchee, Cashmere, Leavenworth, Chelan, and surrounding areas. LOCATION 405 B Ohme Gardens Road - Wenatchee, WAGet Directions Doctors Dr. Jerry Winters Dr. Katy Schneider Dr. Ashley Plantz Dr. Misti LeMoine Join Our Team
