New Client Information Form Mrs.Mr.Ms.Dr. Your Name Fellow Care Giver's Name (if applicable) Street Address: Street Address Line 2: City: State: Postal / Zip Code: Home Phone Work Phone Cell Phone Your Email How did you hear about us? Hospital SignInternetNewspaperPersonal RecommendationOther Other: Whom can we thank? Pet Information Pet's Name Age/Birthday Species (cat, dog, etc.) Breed Color Sex MaleFemale Spayed/NeuteredYesNo Does your pet have allergies? YesNo Has your pet ever had a reaction to vaccines or medications? YesNo List any major surgeries or health issues your pet has had: Missed/Late Appointment Policy Our goal is to provide quality individualized medical care in a timely manner. No-shows, late shows and cancellations inconvenience those individuals who need access to veterinary care. We would like to remind you of our policy regarding missed appointments. A missed appointment is when you fail to show up for an appointment without a phone call or cancel without at least 24-hour notice. A veterinary/client relationship is built on mutual trust and respect. As such, we strive to be on time for your scheduled appointments and ask that you give us the courtesy of a call when you are unable to keep your appointment. However, you are responsible to remember your appointment regardless. In order to be respectful of the medical needs of other patients, please be courteous and call our office promptly if you are unable to show up for an appointment. This time will be reallocated to someone who is in need of treatment. If it is necessary to cancel your scheduled appointment, we require that you call at least 24 hours in advance. Appointments are in high demand and your early cancellation will allow another patient to access timely veterinary care. Late Appointment Policy: An appointment is considered to be late when the client shows up more than 15 minutes past the scheduled arrival time. Clients that are repeatedly late will be asked to reschedule and pay a $50 deposit when scheduling. No-Show Appointment Policy: A “no-show” is a client who misses an appointment without canceling. A failure to be present at the time of a scheduled appointment will be recorded in the patient's chart as a “no-show.” The first time there is a “no-show” or late cancellation there will be no charge to the client. A 2nd occurrence will result in the client being charged a $50 deposit when making appointments. The 3rd occurrence may result in the client being discharged from the practice. Surgery Appointment No-Show Policy: A surgery “no-show” is a client who misses a surgery appointment without providing 24 hours notice of cancellation. The first time this occurs we will call to offer to reschedule the appointment. The second missed surgical appointment will result in the client needing to pay a $100 deposit before scheduling additional surgical procedures. If a third incident occurs, the client may be discharged from the practice. Consent You will be asked to sign a health plan confirming authorization of treatment after a tentative diagnosis. The details of treatment, the risks of treatment, and/or the risk of not treating will be explained to you. Method of payment today Payment is required at the time of service. For your convenience, we accept Mastercard, Visa, American Express, cash, check (with a valid driver’s license) or Care Credit. I hereby grant the Animal Care Clinic the right to use the name and photograph or other likeness of myself and my pet in connection with its social media (ie: facebook) and promotional materials in any and all media including printed material, internet, and film. Signature: Date: Δ
