Creature Comforts Veterinary Hospital
Client Information (Person completing this form)
Primary
*
First Name
Last Name
Secondary
First Name
Last Name
Address (Include Lot or Apt #)
*
City
*
State
*
Zipcode
*
Primary Phone Number (000-000-0000)
*
(000-000-0000)
Landline
(000-000-0000)
Spouse/Other Phone Number
(000-000-0000)
Employer
Employer Phone
(000-000-0000)
Spouse/Other Employer
Spouse/Other Employer Phone
(000-000-0000)
Email Address
example@example.com
Secondary Email Address
example@example.com
Pet Information
Pet 1
Pet's Name
*
Species (Dog, Cat, Rodent)
*
Breed
*
Age/Birth Date
*
Color
*
Is your pet spayed or neutered
*
Male, Not Neutered
Male Neutered
Female, Not Spayed
Female Spayed
Do you want to add another pet?
Yes
No
Pet 2
Pet's Name
Species (Dog, Cat, Rodent)
Breed
Age/Birth Date
Color
Is your pet spayed or neutered
Male, Not Neutered
Male Neutered
Female, Not Spayed
Female Spayed
Do you want to add another pet?
Yes
No
Pet 3
Pet's Name
Species (Dog, Cat, Rodent)
Breed
Age/Birth Date
Color
Is your pet spayed or neutered
Male, Not Neutered
Male Neutered
Female, Not Spayed
Female Spayed
Do you want to add another pet?
Yes
No
Pet 4
Pet's Name
Species (Dog, Cat, Rodent)
Breed
Age/Birth Date
Color
Is your pet spayed or neutered
Male, Not Neutered
Male Neutered
Female, Not Spayed
Female Spayed
Previous Veterinarian
Required for Urgent Care patients.
Which will you be using us for?
*
Urgent Care
Primary Care
By Checking Below, I acknowledge the following policies at Creature Comforts Veterinary Hospital:
*
Professional fees are due at the time services are rendered.
Payment Policies
*
We accept various payment methods, including cash, credit, debit, checks, Scratch Pay, and CareCredit. Please note that the cardholder must be present to utilize CareCredit, and it cannot be processed over the phone. While checks are not permitted during the initial visit, they may be accepted in future visits with proper identification. We retain the right to refuse check payments, and a fee of $25 will be charged for any returned checks.
Cancellation Policy
*
As a new client, I acknowledge that a prepayment equivalent to the exam fee is necessary when scheduling my appointment. I accept that failure to give the required cancellation notice will result in the loss of my prepayment.
No Show/Late Cancellation Policy
*
I acknowledge that a 24-hour notice for cancellation or rescheduling is preferred; however, a minimum notice of 2 hours is necessary to prevent the need for a prepayment for future bookings.
No Show Policy
*
I acknowledge that a 24-hour notice for cancellation or rescheduling an appointment is preferred; however, a minimum notice of 2 hours is necessary to prevent the need for a prepayment for future bookings.
Late Policy
*
I understand arriving late for my appointment, I may not be seen at my scheduled time and will be given the option for a drop-off admission or to reschedule to the next available appointment.
Additional information for our new patients available on our website ccvhankeny.com!
Please check the following directives, if you approve:
Release of medical/vaccination records for my pet(s) to other veterinary clinics/hospitals.
My pet(s) medical/vaccination records to be emailed to my personal email noted above.
My pet(s) photo can be used by Creature Comforts Veterinary Hospital.
Communication Preference
Phone
Email
Text
How did you hear about us?
Electronic Signature
*
First Name
Last Name
Signature
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preview PDF
Submit
Should be Empty: