New Client Form Owner's Name First Middle Last Home PhoneWork 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 / Province / Region ZIP / Postal 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 Who can we thank?* What social media platforms do you use? Facebook Twitter Pinterest Instagram LinkedIn Google+ Other Other Other information the office should know?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.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.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 indicates your agreement with all these policies.Date MM slash DD slash YYYY Pet 1Pet's Name Species Breed Color/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 Color Do you have a second pet? Yes No Pet 2Pet's Name Species Breed Color/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 Color Do you have a third pet? Yes No Pet 3Pet's Name Species Breed Color/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 Color Do you have a fourth pet? Yes No Pet 4Pet's Name Species Breed Color/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 Color Do you have a fifth pet? Yes No Pet 5Pet's Name Species Breed Color/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 Color CAPTCHA Δ Download the form here!
