New Client Information Form

Name: Veterinary Skin & Ear
Address: 11335 Santa Monica Blvd., Los Angeles, CA, 90045, United States
Telephone: 310-855-3499
Price range: $

Complete the form below prior to your first visit!

Owner Information

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Cell phone *

Home phone

Work phone

What is your preferred method of contact for general communication? *

Please list any person who is authorized to make medical or financial decisions regarding this patient. *

For initial exams, we require at least one owner present

Authorization and Payment Policy

I hereby authorize the veterinarian to examine, prescribe or treat the above patient. I assume full responsibility for all charges incurred in the care of this animal. I also understand that these charges are to be paid in full at the time of release. Payments are expected when services are rendered. WE DO NOT BILL. In order to provide the best care, we accept: all major credit cards (MasterCard, Visa, Amex, & Discover), Care Credit, and cash. Should collection and/or attorney’s fees become applicable I will be held responsible for those and all other costs of collection. By signing below, I hereby state that I am the owner or authorized agent of the above patient. We are teachers in the field of veterinary dermatology. Medical files, case information and/or photos may be used in teaching, continuing education, website, veterinary literature, and the like. I authorize the release of case/patient information for such purposes; client confidentiality (Names and Personal Information) will be maintained. I understand that no guarantee can be made as to the result obtained from medical treatment. I have read the above terms and conditions and agree to adhere to this agreement. *

I agree

Signature *

Name

Have a question?

If you need anything at all, our contact information is below.

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Contact

Phone: 310-855-3499
Email: info@vetskinear.com

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Location

11335 Santa Monica Blvd.
Los Angeles, CA 90025

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Hours

Mon: 7:30 am - 3:30 pm
Tue: 11:00 am -7:00 pm
Wed - Fri: 7:30 am - 3:30 pm
Sat - Sun: Closed

Parking:

Two parking lots are available behind the clinic.

Get in Touch!

Complete the form below, and we'll be in touch with you shortly. If you need immediate assistance, please call us directly at 310-855-3499.