New Client/Patient Form

New Client/Patient Form
How Did You Hear About Village Animal Clinic

Drove ByYellow PagesInternet SearchWebsite
Personal Recommendation (We would like to thank them)
Client Information
Name*

First NameLast Name
Date of Appointment
Spouse/Significant Other (person authorized to make decisions regarding your pet)

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / County

Postal / Zip Code
Primary Phone Number*

Area CodePhone Number
Secondary Phone

Area CodePhone Number
Can We Text you at these Numbers?
If yes to texting. Is it to Primary Number, Seconday Number or Both
Primary email address (for us to communicate with you)_*
example@example.com
Person Responsible for Payment

Vaccine History(indicate month and year done)
Rabies Month and Year
Canine Distemper/Parvo Month and Year
Leptospirosis Month and Year
Bordetella Month and Year
Lymes Month and Year
Heartworm Blood Test Month and Year
Fecal (stool sample) Test Month and Year
Feline Distemper Month and Year
FELV/FIV Blood Test Month and Year
Any Known Allergies
Previous Diagnosed Conditions
Medical Records Waiver
PLEASE CHECK ONLY ONE BOX

All medical Information may be released to any individual or organization for all my pets registered on my accountOnly vaccine history and heartworm/fecal testing may be released to any individual or organization for all my pets registered on my account. No other medical information shall be releasedNo medical information or any vaccination history shall be released to any individual or organization with my expressed written consent pertaining to all of my pets registered on my account
Signature

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Date

MonthDayYear
Date

PLEASE READ AND ACCEPT OR DECLINE
Village Animal Clinic is authorized to post pictures of my pet(s) online via facebook, instagram, twitter or the Village Animal Clinic website. Only your pets first name will be used. (PLEASE CHECK ONLY ONE BOX)

AcceptDecline

Village Animal Clinic Financial Policy

Payment

Payment is due at time of services

We accept cash (we are unable to accept bills $50.00 or higher), check, credit card (Visa, Mastercard, American Express & Discover) and Care Credit. Care Credit is a great tool for paying for veterinary care and can be used in some human medical offices. Go to www.carecredit.com to apply online. The status of your application will be available within minutes, and you will receive a care credit account number. Depending on the amount being put onto the account, you may be eligible for a 6-month deferment program (6 months to pay off balance without incurring a finance fee)

A deposit of 50% of the estimated cost of care is required for patients requiring hospitalization, for medical or surgical services with an estimate of greater than or equal to $500, and at the discretion of Village Animal Clinic. The remaining balance is due each day at time of pick up.

Outstanding Balances

Effective immediately, ALL outstanding balances must be paid in full prior to additional services.

A monthly finance charge of 1.5% will be added each month the balance is unpaid.

Check Payments

I understand that if a bank should fail to honor any check, the entire unpaid balance shall be considered in default. I will be charged a return check fee of $25.00 and a monthly service charge of 1.5% will be charged on the remaining balance.

I understand and agree to the above policies
Signature*

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Should be Empty:

New Client/Patient Form

Client Information

Patient Information

Vaccine History(indicate month and year done)

Medical Records Waiver

PLEASE READ AND ACCEPT OR DECLINE