New Patient and Client Information

Owner's Name *

First Name Last Name

Co-owner's Name

First Name Last Name

Primary Contact Number *

Area Code Phone Number

Primary Contact Number *

Cell Phone Landline

Secondary Contact Number

Area Code Phone Number

Secondary Contact Number

Cell Phone Landline

Email *

example@example.com

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Owner's Drivers License Number *

Owner's Date of Birth *

Date

Owner's Employer

Owner's Work Number

Area Code Phone Number

Co-owner's Employer

Co-Owner's Work Number

Area Code Phone Number

Do you have a preferred Doctor you would like to see? *

How did you hear about Friendswood Animal Clinic? *

Patient #1's Name *

Dog or Cat *

Date of Birth or approximate age *

Sex *

Breed *

Mixed or unknown is acceptable

Color *

Any prior illnesses or surgical history we should know about? *

Please send previous vet history to friendswood@nva.com or fax 281-482-5001.

Any known DRUG ALLERGY or VACCINE REACTIONS we should know about? *

Please send previous vet history to friendswood@nva.com or fax 281-482-5001.

Do you have another pet to add? *

Yes No

Patient #2's Name *

Dog or Cat *

Date of Birth or approximate age *

Sex *

Breed *

Mixed or unknown is acceptable

Color *

Any prior illnesses or surgical history we should know about? *

Please send previous vet history to friendswood@nva.com or fax 281-482-5001.

Any known DRUG ALLERGY or VACCINE REACTIONS we should know about? *

Please send previous vet history to friendswood@nva.com or fax 281-482-5001.

Do you have another pet to add? *

Yes No

Patient #3's Name *

Dog or Cat *

Date of Birth or approximate age *

Sex *

Breed *

Mixed or unknown is acceptable

Color *

Any prior illnesses or surgical history we should know about? *

Please send previous vet history to friendswood@nva.com or fax 281-482-5001.

Any known DRUG ALLERGY or VACCINE REACTIONS we should know about? *

Please send previous vet history to friendswood@nva.com or fax 281-482-5001.

Signature *

Clear

Date of Signature *

Date

Method of Payment *Care Credit is NOT accepted *

Visa Mastercard American Express Discover Check Cash

Will you allow us to take photos of your pet to use on our social media? *

Yes No

I authorize and grant Friendswood Animal Clnic to take photos of my pet regarding my experiences with them.
I grant Friendswood Animal Clinic to use my pet's photos on Facebook, Twitter, Instagram and other social media platforms.
I allow Friendswood Animal Clinic to edit, alter, copy or distribute the photos for social media advertising and marketing.
I agree that the photos belong to Friendswood Animal Clinic.
I understand that I will not receive any monetary compensation.

Signature *

Clear

Date *

Date

MISSED APPOINTMENT POLICY

Our goal is to provide quality individualized medical care in a timely manner. No-shows and late arrivals inconvenience those individuals who need access to veterinary care. We would like to inform 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. As a courtesy, we provide reminder calls/emails/texts before your appointment. However, you are responsible to remember your appointment regardless.

Late Arrival Policy – We make every effort to be on time for all our appointments. Unfortunately, when even one patient arrives late, it can throw off the entire schedule for that day. In addition, rushing or “squeezing in” an appointment short changes the patients and contributes to decreased quality of care. Therefore, a client that arrives 10 minutes or more late to their scheduled appointment may be asked to reschedule. The hospital also reserves the right to charge a Late Fee of $63 should the appointment need to be rescheduled. This fee will be credited to the client's account at their next scheduled appointment. We apologize for any inconvenience this might cause.

Appointment No-Show: A “no-show” is if a client misses an appointment without cancelling it. A failure to be present at the time of a scheduled appointment will be recorded in the patient’s chart as a “no-show”. There will be a $63 charge if you do not show up for your appointment and have not called the hospital to cancel. We will call for payment or place this charge on your account.

Surgery Appointment No-Show Policy: A surgery “no-show” is a client who misses a surgery appointment without providing 24 hours notice of cancellation. There will be a $100 charge if you do not show up for your appointment and have not called the hospital to cancel. We will call for payment or place this charge on your account.

New Patient and Client Information

Owner Information

Patient Information

Authorization

Social Media Photo Release Authorization