Online Forms

New Client Form

Palms West Veterinary Hospital offers our patient form online so you can complete it in the convenience of your own home or office.

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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.

CLIENT (OWNER)

Name *

First

Last

Home Phone *

Cell Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

PATIENT (PET)

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Pet's Name *

Breed *

Color

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Age/Date of Birth

Microchip Number

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Species

Dog
Cat
Other

Sex

Male
Female

Spayed/Neutered

Current Medications

Please select any of the following symptoms that your pet may be experiencing

Behavioral Changes
Depression
Weight Loss or Gain
Weakness
Loss of Appetite
Gagging
Vomiting
Diarrhea
Breathing Issues/Coughing/Sneezing
Thirst
Increased Urination
Seizures

Primary Care Veterinarian

Multiple Choice

I, the undersigned, owner of admitted patient or current guardian of patient, hereby authorize Palms West Veterinary Hospital and/or any authorized staff, to administer such treatment as is necessary, and to perform such additional procedures as are considered therapeutically and/or diagnostically necessary, and certify that no guarantee or assurance has been given as to the results that may be obtained. Further, I assume all financial responsibility for the charges incurred to this patient, consent to release medical information and authorize direct payment to Palms West Veterinary Hospital. I understand that I am fully responsible to pay for my examination today as well as any additional diagnostics, testing, or treatments that are provided to my pet. By signing this form, I realize that if I fail to pay today, I am liable for all collection costs, up to 100%, incurred for this account. We also have permission to use off-label medications as deemed necessary.

I consent to have photos and/or case study information pertaining to my Pet placed on our website or Facebook for education or informative purposes for our online users. Please select one of the following:

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Client's Signature *

Clear Signature

Date

Have a Questions?

Please don’t hesitate to reach out with the contact information or send a message using the form.

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Address

556 Folsom Rd.
Loxahatchee Groves, FL 33470

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Contact Information

Phone: 561-798-2780
Fax: 561-793-2601
Email: palmswestvet@gmail.com

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Hours

Mon – Sat: 8am to 6pm
Sun: CLOSED

Name *

First

Last

Email *

Phone

How can we help you? *