New Client Form "*" indicates required fields Owner's Name* First Middle Last Home Phone*Work PhoneCell PhoneEmail* What is your preferred method of contact?* Phone Email Spouse/Partner/Co-Owner's Name First Middle Last Home PhoneWork PhoneCell PhoneAddress* Street Address Address Line 2 City State 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 ZIP Code How did you learn of our hospital?* Saw Our Hospital / Location Google (or other search) Yellow Pages (print) Facebook Online Review Site Client Referral Other Who can we thank?*What social media platforms do you use? Facebook Twitter Pinterest Instagram LinkedIn Google+ Other OtherOther information the office should know?NEW CLIENT APPOINTMENTS When you schedule an appointment, the time is reserved exclusively for you. You are reserving the resources of the Beachwood Animal Clinic doctor, support staff, and facilities required to make your appointment successful. Canceled appointments with little or no notice often cannot be filled, and another sick pet may not be able to be seen. During this pandemic environment, pets are going without care because veterinarians everywhere are at full capacity – this means every single time slot is critical in pets getting the care they need and deserve. To do our best to honor new clients, existing clients, and our staff, we require a deposit in the amount of your full office visit to reserve your new client appointment. When you keep your appointment, your deposit is applied to the cost of that visit. If you cancel your appointment with more than 24 hours’ notice, your deposit will be refunded to you, or you can choose to keep it on your account as a credit, which can be applied to another new client appointment. If you cancel your appointment with less than 24 hours’ notice, or do not show up for your appointment, you will forfeit your deposit without exception. Any delay beyond 15 minutes will likely result in your appointment being canceled and your deposit being forfeited. We will collect your credit card information over the phone when you call to schedule your pet’s appointment, or if you schedule through our app, we will call you. Thank you for your cooperation and understanding – we can’t wait to meet you and your furry best friend!I understand the above New Client Appointments policy* I understand CANCELLATION POLICY Due to an increased number of missed appointments and last-minute cancellations, we will now require 24 hours notice for the cancellation of an appointment. Multiple missed appointments or those canceled without 24 hours notice may incur a cancellation fee of $25.00 per pet scheduled to be seen, payable prior to booking future appointments. As an ever-growing practice, every appointment slot is valuable to us and our patients. Missed appointments and last-minute cancellations are times when sick pets could have received care. We ask that you make every effort to arrive on time. Patients arriving 15 or more minutes late may need to be rescheduled and may incur a cancellation fee.I understand the above Cancellation Policy* I understand PRESCRIPTION PROCESSING FEE Please be advised that there is a $7.00 processing fee for the authorization of any online prescriptions that are not processed through Beachwood Animal Clinic’s online pharmacy, as evaluating the high number of requests from outside online pharmacies takes a significant amount of time and effort by our staff. By utilizing Beachwood Animal Clinic’s online pharmacy, you’ll save money, support a local independent business, and allow our team to spend more time directly on patient care. Thank you for your understanding, and if you have any questions or would like assistance getting started with our online pharmacy, please don’t hesitate to speak with a staff member. I understand the above Prescription Processing Fee* I understand Financial Policy* OUR OFFICE ACCEPTS VISA, MASTERCARD, DISCOVER AND CARE CREDIT, ALONG WITH CASH. WE DO NOT ACCEPT CHECKS. FULL PAYMENT IS DUE AT THE TIME OF SERVICE. CLIENTS WITH PAYMENT CONCERNS ARE ASKED TO SPEAK TO A CLIENT SERVICE REPRESENTATIVE BEFORE THEIR EXAM. OUR STAFF IS HAPPY TO PROVIDE ANY CLIENT WITH A WRITTEN TREATMENT PLAN PRIOR TO SERVICES BEING RENDERED. CLIENT WILL BE RESPONSIBLE FOR A 1.5% MONTHLY FINANCE CHARGE ON ACCOUNTS OVER 30 DAYS AND ANY COLLECTION FEES ON ACCOUNTS OVER 90 DAYS. AS OF SEPTEMBER 1, 2015, WE OFFER 6 MONTHS, NO INTEREST FINANCING VIA CARE CREDIT FOR CLIENTS IN NEED A CREDIT PLAN. NO OTHER PAYMENT PLANS ARE OFFERED AT THIS TIME.Transferring Records Consent* TRANSFERRING RECORDS CONSENT: I UNDERSTAND THAT MY PET’S INFORMATION CAN BE GIVEN TO RESCUE GROUPS, SPECIALTY PRACTICES, OTHER VETERINARY OFFICES, AND BOARDING AND GROOMING FACILITIES SHOULD YOU (THE OWNER) GIVE THEM OUR CONTACT INFORMATION TO REFER TO.Treatment Consent* I HEREBY AUTHORIZE THE VETERINARIAN TO EXAMINE, PRESCRIBE FOR OR TREAT THE BELOW-DESCRIBED PET(S) TO THE BEST OF THEIR ABILITIES. I ASSUME RESPONSIBILITY FOR ALL CHARGES INCURRED IN THE CARE OF THIS ANIMAL. I ACKNOWLEDGE THAT MEDICAL INFORMATION WILL NOT BE RELEASED TO ANYONE NOT INDICATED ON THIS FORM WITHOUT MY EXPRESS PERMISSION.We love social media! Do we have your permission to share your pet(s)’ image and story on social media, our website & other forms of related media?* Yes No SignatureYour signature below indicates your agreement with all these policies.Date MM slash DD slash YYYY Pet 1Pet's NameSpeciesBreedColor/Markings:Vaccinations were last given by (clinic name)Allergies or Long-term Medical Problems:Birth Date MM slash DD slash YYYY Sex Male Female Spayed/Neutered? Yes No Not sure ColorDo you have a second pet? Yes No Pet 2Pet's NameSpeciesBreedColor/Markings:Vaccinations were last given by (clinic name)Allergies or Long-term Medical Problems:Birth Date MM slash DD slash YYYY Sex Male Female Spayed/Neutered? Yes No Not sure ColorDo you have a third pet? Yes No Pet 3Pet's NameSpeciesBreedColor/Markings:Vaccinations were last given by (clinic name)Allergies or Long-term Medical Problems:Birth Date MM slash DD slash YYYY Sex Male Female Spayed/Neutered? Yes No Not sure ColorDo you have a fourth pet? Yes No Pet 4Pet's NameSpeciesBreedColor/Markings:Vaccinations were last given by (clinic name)Allergies or Long-term Medical Problems:Birth Date MM slash DD slash YYYY Sex Male Female Spayed/Neutered? Yes No Not sure ColorDo you have a fifth pet? Yes No Pet 5Pet's NameSpeciesBreedColor/Markings:Vaccinations were last given by (clinic name)Allergies or Long-term Medical Problems:Birth Date MM slash DD slash YYYY Sex Male Female Spayed/Neutered? Yes No Not sure ColorCAPTCHA Δ
