A full-service veterinary hospital
serving Poulsbo's pets since 1952.

Craig Adams, DVM, MS
Bethany Adams, DVM
(360) 779-4640

Poulsbo Animal Clinic
19494 7th Ave, Ste 100
Poulsbo Village Shopping Center
Poulsbo, WA 98370
(360)779-4640
(360)779-2675 fax

American Animal Hospital
Association

Form - New Client Registration Form

Please fill out this form prior to your first visit. It may also be filled out in person. In that case, please arrive about 10 minutes early for your appointment.

Name (required)
First Name (required)	Last Name (required)

Spouse or Co-owner's name
First Name	Last Name

Address (required)
Street Address (required)


City (required)	State/Province (required)	Zip/Postal Code (required)
,

Phone (required)
Phone Type	Phone Number (required)

Phone
Phone Type	Phone Number

Phone
Phone Type	Phone Number

E-Mail Address (required) :

Former Veterinary Hospital(s)

Pet's name (required)

Dog

Cat

Pet's breed (required)

Male

Female

Neutered/Spayed

Intact (not neutered or spayed)

Pet's date of birth (list approximate if unknown) (required)

Reason for visit. Please list any pertinent history, medications, and treatments.

Please list any other pets and their information

How did you hear about Poulsbo Animal Clinic?

Drive by

Yellow Pages: Yellowbook

Yellow Pages: Dex

Yellow Pages: CenturyLink

Internet: Google

Internet: Bing

Internet: Yahoo!

Internet: Yelp or Manta

Internet: LocalVets.com/YextVets.com

Newspaper

Referral by a friend

Whom can we thank for the referral? We will send them a $20 coupon!

Payment Policy
Full payment is due at the time of service. Acceptable forms of payment are: cash, personal check, or credit/debit cards. We also accept CareCredit, which may allow you to spread out your payments over time. Some CareCrediit policies are at zero interest. You can apply for CareCredit prior to your visit (please follow the links on our home page), or in person when you arrive. Cancellation policy: Poulsbo Animal Clinic works by appointment only (but are happy to see you on an emergency basis during business hours if necessary, but appreciate a call before you arrive). We request 24 hours notice for changes or cancellations. Due to the number of missed appointments by some clients in the past, we may assess a cancellation fee. I have read and agree to the policies as stated above. I authorize Poulsbo Animal Clinic to treat my pet. I understand that I may request a written estimate at any time and agree that full payment will be made at the time of service.

By initialing below, I acknowledge that I have read and agreed to the above statements.

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A full-service veterinary hospital serving Poulsbo's pets since 1952.

Craig Adams, DVM, MS Bethany Adams, DVM (360) 779-4640

Form - New Client Registration Form

A full-service veterinary hospital
serving Poulsbo's pets since 1952.

Craig Adams, DVM, MS
Bethany Adams, DVM
(360) 779-4640