Client Info Form Client Info Form Please fill out this form to shorten your check in time. We ask that this information be updated yearly to streamline all communications for you and your pets, thank you! CLIENT INFORMATION Name* First Last Address* Street Address Address Line 2 City VirginiaAlabamaAlaskaAmerican 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 State ZIP Code What county do you live in?* Primary Contact Number (include area code)*Employer* Driver's License Number Email* Spouse's Name Spouse's Primary Contact Number PATIENT INFORMATION Pet's Name* Breed?* Color?* Male or Female?*Please SelectMaleFemaleDate of birth/ estimated age?* Spayed or Neutered?*Please SelectSpayedNeuteredIntactHas your pet been to a veterinarian before?* Yes No Where was your pet previously seen? Do you have pet insurance?* Yes No What company is your pet insurance through? Referred by:*Please SelectRadioSocial MediaFlyerPrintDigitalFriend or RelativeOtherOther: POLICIES Please check each box indicating that you understand the following policies. 1. Cancellation policy* We require 24-hour's notice for cancellation of any appointment or procedure.2. Late policy* If you are more than 5 minutes late to your scheduled appointment you will need to reschedule.3. Drop off appointments* Plan on your pet being discharged at 5:30pm. The DVM will call you once they have looked at your pet and come up with a treatment plan. This call may not happen until later in the afternoon.4. Prescription refills* Prescription refills require 48 business hours' notice. There is an additional fee for urgent refills needed immediately.5. Medical Records* Previous medical records must be provided at least 24 hours before your pet's appointment. It is important for us to have that information ahead of time and for the doctor to have time to review it.6. Payment due at time of policy* Methods of payment accepted as Cash, Credit, Care Credit. We do not accept checks. DISCLOSURE OF HOURS In accordance with state law, we are required to provide you with a disclosure of our business hours. During the times listed below, our facility is open and fully staffed. When the hospital is closed, there are no employees or caretakers on the premises. Any animals remaining at the clinic after the hours listed below will be unattended. Hospital Hours MONDAY - FRIDAY: 7:30AM - 6PM SATURDAY - SUNDAY: CLOSEDDisclosure of Hours* I understand the above disclosure of hoursSignature* Reset signature Signature locked. Reset to sign again Δ In
