Client Registration

Client Registration

We thank you for the opportunity to provide veterinary care for your pet family member. Please take a few moments to fill out this form as completely as possible
Owner Name (Must be 18 years old or older and able to make medical and financial decisions)

Prefix First Name Last Name
Home Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number
Mobile Phone Number
Email
example@example.com
I authorize Cane Bay Veterinary Clinic to use the following methods to contact me with reminders, test results and other general communication. Please check all that apply.

Text messages Email Phone Call
Employer:
Work Phone Number
Spouse/Co-Owner Name (Must be 18 years old or older and able to make medical and financial decisions on your behalf)

Prefix First Name Last Name
Spouse/Co-Owner Mobile Number
Spouse/Co-Owner Email
example@example.com
I authorize Cane Bay Veterinary Clinic to use the following methods to contact my spouse/co-owner with reminders and test results. Please check all that apply.

Text messages Email Phone Call
Spouse/Co-Owner Employer:
Spouse/Co-Owner Work Number
What is your preferred contact method
Other person(s) authorized to make medical decisions for your pet on your behalf:
Must be 18 years old or older and able to make financial decisions on your behalf
All fees are due at the time services are rendered. If you wish to pay by check, credit card, bank card or debit card, please complete the following:
Driver's License # Expiration Date
How did you hear about us?
Referred by:
We love Social Media! May we share your pet's picture and story on our social media accounts, website and other forms of related media?
Does your pet have a social media account? Please share it with us below
We feed our patients a lot of treats including peanut butter, cheese, tuna, baby food, etc. Please let us know if any member of your family has a food allergy?
Financial Policy:

Our office accepts Visa, Mastercard, Discover, Care Credit and ScratchPay, along with cash and checks (only with current DL information on file). Full Payment is due at the time of service. Clients with payment concerns are asked to speak to a Client Service Representative before their exam. We will always provide every client with a written treatment plan and cost break down prior to services being rendered. Client will be responsible for 1.5% monthly finance charge on accounts over 30 days and any collection fees on accounts over 90 days. Clients will be responsible for a $50 fee on any returned check. We offer 6 months, no interest financing via ScratchPay and Care Credit for clients in need of a credit plan. No other payment plans are offered at this time. Your signature below indicates your agreement with this policy.
Clinic Policies:

By signing below, I acknowledge and accept the following policies of Cane Bay Veterinary Clinic

1. Cancellation Policy - Please provide at least 24 hours notice for cancelling any appointment as this allows us to fill your reserved spot with another pet that is in need of our services. We understand that emergencies do arise on occasion and cancellations need to be made at the last minute. If a client misses 2 appointments without calling to cancel in a timely fashion, a $50 non-refundable deposit will be required to book future appointments. This deposit will go toward the exam fee when the pet is seen. Otherwise, drop-off appointments can be booked without a deposit.

2. Multi-Pet Booking Policy - We require a $50 non-refundable deposit per pet for any client booking appointments for multiple pets in one day. The deposit will go toward the exam fee when the pet is seen.

3. Prescription Policy - We do not work directly with third-party pharmacies such as Chewy, 1-800-PetMeds, etc. due to the time it takes our staff to process these orders and prescription errors made by these pharmacies. If you would like to utilize one of these pharmacies we will gladly provide you with a written prescription that you can mail to the pharmacy of your choice. If a written prescription is requested outside of an appointment time or for a medication that we carry in the clinic, there will be a medical records review fee charged to the client. This covers the doctors time to review the patient’s medical record to ensure that the medication being prescribed is appropriate and safe for the pet. The fee is $5. You are also welcome to use Vetsource, our home delivery service. We will process these scripts electronically as the medical records review fee is included in the cost of the medication, when ordered through Vetsource.
Treatment Consent:

I hereby authorize the veterinarians of Cane Bay Veterinary Clinic to examine, prescribe for or treat the below-described pet(s) to the best of their abilities. I assume responsibility for all of the charges incurred in the care of this animal.

To prevent the spread of parasites, any hospitalized pet with noticeable fleas will be treated with an oral flea medication on admission, and the prescription price will be included on the invoice.

At Cane Bay Veterinary Clinic we recommend that all pets have current vaccines to prevent the spread of infectious disease while in our care. Rabies vaccination is required by law and any pet treated by Cane Bay Veterinary Clinic is required to be current on this vaccination unless the veterinarian deems it medically inappropriate. The price of this vaccine will be included on the invoice if given.

I AUTHORIZE ADMINISTRATION OF VACCINES AND PARASITE CONTROL AS NEEDED FOR MY PET(S).
Signature

Clear
Date

Month Day Year
Date
Pet Information

Space is provided for two pet's information. If you have additional pets, please fill out a second form.
Pet Name #1:
Date of Birth or Age
Species
Breed
Sex
Color/Markings
Allergies or Long Term Medical Problems:
Previous Veterinarian
If your pet has pet insurance, who is the provider?
Please upload a picture of your pet here

Cancel of
Pet Name #2:
Date of Birth or Age
Species
Breed
Sex
Color/Markings
Allergies or Long Term Medical Problems:
Previous Veterinarian
If your pet has pet insurance, who is the provider?
Please upload a picture of your pet here

Cancel of
Should be Empty:

Client Registration

Pet Information