New Client Form

Spouse or Secondary Owner:

Please complete information for all of your pets – Thank you!

In this document, “Patient” refers to any pet receiving treatment. “Client” refers to any person(s) acting on behalf of the Patient. Use of the word “I”, “you”, “your” or “me” refers to the Client.

“Provider” refers to the hospital and the hospital’s staff, which include but are not limited to: other licensed independent practitioners and any authorized agents, contractors or affiliates acting on their behalf.

• 1. Consent to Treatment. I consent to the procedure(s) which may be performed during any and all office visits, but not limited to, routine and emergency treatment or services, which may include laboratory work, radiographs, diagnostic procedures. Also included are medical, nursing or surgical treatments/procedures, anesthesia or hospital services rendered as ordered by the Provider for Patient(s) under my care.
• 2. Responsible Agent. If at any time I cannot present Patient for care, I understand that it is my responsibility to notify Provider of the name and contact information of my proxy. I understand my proxies must be over 18 years of age. Unless notified otherwise, in my absence, I authorize the following person(s) to make any and all medical, financial and other care decisions including Euthanasia orders for Patient.

• 3. Release of Information. I hereby permit Provider and previous providers to release healthcare information for purposes of treatment, payment or healthcare operations. Healthcare information regarding prior admission(s) at other facilities may be made available to coordinate Patient care or for case management purposes. This information may include history and physical, emergency records, laboratory reports, diagnostics, imaging, operative reports, physicians notes, support staff notes and consultations, etc.

• 4. Consent to Photograph and Video. I hereby permit Provider, its representatives and employees the right to take photographs of my pet, edit, use and publish in print or electronically. I agree the Provider may use such photographs of my pet with or without our name and for any lawful purpose, including publicity, illustration, advertising and web content. (Please select consent below).

• 5. Allergens. Items known to cause allergic reactions in humans may be used when providing care for your pet(s). Common items are peanut butter, fish, penicillins, etc. Please alert staff if these, or any other allergens, should be avoided with your pet(s).

• 6. No Show/ Late Cancellation Policy. Clients who miss or cancel an appointment without 24 hours notice will be subject to a No Show fee of $56.99. Prepayments are required for any new client, clients with a history of multiple cancellations, surgical or imaging appointments, or any client who has not actively been seen in our office within the last 12 months, therefore, if a client is to cancel that appointment, the cost is non-refundable. This fee will not be placed on the Clients account to use towards future service(s). It is the responsibility of the client to pay any outstanding fees prior to scheduling their next appointment.

  • This policy has been established in order to provide the highest level of veterinary care to all of our patients. By providing us with a notice of cancellation, we may be able to accommodate other patients with that time slot. We do understand that emergencies arise and that it may not be possible to give such notice. Exceptions to this policy will be determined by management.

• 7. Financial Agreement. In consideration of the services to be rendered to Patient, Client or Guarantor individually promises to pay the Patient’s account. An estimate of the anticipated charges for services/procedures/medications, etc. will be provided before services are rendered. Estimates may vary from the final charges based on a variety of factors including, but not limited to, the course of treatment, intensity of care and the necessity of providing additional goods and/or services.

  • I understand a deposit may be required for exams, procedures, diagnostics, surgeries, medications, etc. I also understand that the outcome of care does not change the Client’s obligation to pay for services.

  • All payments are due before any services will be rendered.

  • Once all laboratory tests are submitted and services are rendered the fee paid is non-refundable for all tests and services.

• Acknowledgement. I hereby warrant and represent that I am the owner of Patient(s). I am 18 years of age or older and have carefully read through all terms and conditions. By signing, I agree to all terms and conditions as mentioned in this document.