New Client Form

General Information

Owner's Name *

Co-owner's Name

Address, city, state *

Zip Code *

Email Address *

Phone number *

Secondary phone number

Name and phone number of previous clinic*

Preferred form of communication PhoneEmail

How did you hear about us?

Other Information

Do we have permission to use your pet's picture on our website and social media?

YesNo

Please Read - Financial Responsibility

For your convenience, we will accept payment in the form of Cash, Check, Visa, Mastercard, American Express, and Discover. We also conveniently accept Scratchpay & Care Credit. By submitting this form, I agree I am responsible for any charges incurred by my pet and that payment is due at the time of service. Delinquent accounts will be assessed interest at a rate of 18% per annum. Should it become necessary to place a delinquent account with a collection agency, a collection fee of up to 35% of the principal balance due will be added to defray the cost of collection. Additionally, if legal action is necessary to collect the delinquent account I/we understand that I/we will be responsible for all costs of collection to include but not limited to court costs, interest, and attorney fees. In any of these events, a credit report may be pulled.

Also Note

If during your appointment, your pet(s) are unable to be examined due to temperament, a call fee and consultation fee will be charged so that we are able to legally give recommendations, and possibly prescribe medication for future visits should they need it.

Cancellation Policy & Fee

We understand that there are times when you must miss or reschedule an appointment due to emergencies or unexpected situations. Cancellations within 24-48 business hours also prevent us from treating another patient in need, particularly given the logistics of scheduling appointments geographically.

To provide the best care and availability for all of our patients, cancellations/reschedules within 24 business hours will incur a cancellation fee of $65. If you have a Monday appointment, please notify us before 5:00 pm on the preceding Thursday to avoid this fee, while allowing us to serve our patients to the best of our ability. Cancellations/reschedules made after this time, or failure to attend a scheduled appointment, will incur the $65 fee. (This excludes euthanasia appointments, as we understand that a pet’s condition can sometimes improve and these appointments may no longer be necessary.) Thank you for your understanding and cooperation in helping us serve all our clients and patients effectively.

Authorized Signer *

Printed Name *

Date *