MVC New Client Paperwork

MVC New Client Paperwork
Today's Date:

Month Day Year
Date
Appointment Date

Month Day Year
Date
Owner:
Co Owner/Spouse:
Address:
City:
State:
Zip:
Email:
example@example.com
Owner Date of Birth:

Month Day Year
Date
Owner SS#
How did you hear about us?

Google/Yahoo! Facebook Drive By Word of Mouth Referred
Home Phone- HIDDEN FIELD
Referred by:
Cell Phone:
Work Phone:
Pet Information
Pet's Name:
Pet Information

Dog Cat Other
List if other than Dog or Cat
Sex:

Male Female
Spayed or Neutered?

Yes No
Breed:
Color:
Age or DOB:
If date of birth is unknown, enter estimate age
Current Medication(s):
Primary Reason for Visit Today:
Please check any symptoms or problems you are having with your pet:

Appetite Loss Scratching Behavioral Changes Breathing Problems Bad Breath Diarrhea Loss of Balance Coughing Vomiting Shaking Head Limping Other:
Other:
Authorization

I hereby authorize the veterinarian to examine, prescribe for or treat the above described pet. I assume responsibility for all charges incurred in the care of the animal. I also understand that ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. Maurice Veterinary Clinic does not accept checks for small animal services.
Signature of client responsible for pet:

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Today's Date

Month Day Year
Date
MAURICE VETERINARY CLINIC

I hereby authorize the veterinarians at Maurice Veterinary Clinic, LLC and their assistants to examine and/or perform procedures they deem necessary for my animals. These procedures include, but are not limited to, the administration and maintenance of anesthesia, and the performance of surgery or any treatment deemed necessary by the attending veterinarian.
I acknowledge and understand that there are risks involved in handling animals and in their medical treatment. I further acknowledge that there is no guarantee as to the result of any treatment made by Maurice Veterinary Clinic, LLC. I agree to hold Maurice Veterinary Clinic, LLC and all employees or associates harmless in the event of unforeseen incidents while my animal is under the care of Maurice Veterinary Clinic, LLC. I understand and agree that Maurice Veterinary Clinic, LLC does not accept or assume liability for accident, escape, injury or death of my animal at any time. I agree that this release of liability will remain in effect for all animals that I own presently and in the future. I agree that should I choose to revoke this release of liability, I will do so in writing. The written request to revoke the release of liability will not be effective until signed by the owner of Maurice Veterinary Clinic, LLC, Dacques C. Pourciau, DVM. At the time of revocation, Maurice Veterinary Clinic, LLC will unconditionally reserve the right to refuse any further services for any of my animals I own presently and in the future. I am the legal owner or the representative of the legal owner of the animal/animals I present for diagnosis and treatment. I am over the age of 18 years.

I give permission to Maurice Veterinary Clinic, LLC to release all requested medical records on any pet or pets that were listed under my account at any time. These records may be released via mail, fax, email or personal delivery to any veterinary clinic, foster or person that had requested such records. It IS NOT the responsibility of Maurice Veterinary Clinic, LLC to validate or verify association of person requesting records. Maurice Veterinary Clinic, LLC, its employees or agents will not be held liable for the release of any records to an unauthorized person unless they are listed below.
I grant Maurice Vet Clinic permission to post my pet/pets picture, story and medical information on social media. I hereby authorize the veterinarian to examine, prescribe for or treat the above described pet. I assume responsibility for all charges incurred in the care of the animal. I have read, understand and signed our “Financial Policy.” ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES. Personal checks are not accepted for small animal services.
Name:
Phone
Signature of client responsible for pet:

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Today's Date

Month Day Year
Date
THE FINANCIAL POLICY OF THE MAURICE VETERINARY CLINIC
Thank you for choosing Maurice Veterinary Clinic. Our primary mission is to deliver the best and most compassionate veterinary care available to your pet. Furthermore, we are committed in making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options. Maurice Veterinary Clinic requires payment in full at the end of your pet’s visit and/or at time of discharge. We only ask that you understand your responsibility and for the payment of your account balance.

Our basic financial policy is the following:
FULL PAYMENT IS DUE AT THE TIME OF SERVICE
- WE ACCEPT CASH, MONEY ORDER, VISA/MASTERCARD, AMERICAN EXPRESS orDISCOVER
CARE CREDIT OFFERS CONVIENIENT MONTHLY PAYMENTS ALLOW YOU TO BEGIN TREATMENT TODAY AND PAY OVER TIME AVAILABLE FOR ANY TREATMENT AMOUNT CAN BE USED REPEATEDLY FOR YOUR ENTIRE FAMILY WITHOUT REAPPLYING IF YOU HAVE PET INSURANCE, WE ARE HAPPY TO PROVIDE YOU WITH THE NECESSARY DOCUMENTATION FOR YOU TO SUBMIT A CLAIM TO YOUR INSURANCE COMPANY. BUT IN NO WAY ARE WE RESPONSIBLE FOR YOUR AGREEMENT WITH THE INSURANCE PROVIDER.

Missed or cancelled appointments without 24 hours will carry a $35.00 service fee.

For some treatments or hospitalized care, a 50% deposit may be required. Healthcare plans requiring comprehensive care of more than $500.00 will require a 50% deposit to begin your pet’s treatment.
YOUR OBLIGATION
All customers are responsible for full payment at the time of service. You are responsible for payment regardless even if a final bill is not completed at time of your visit.
CLIENT RESPONSIBLTY AND ADDITIONAL TERMS
Accounts unpaid after 45 days from day of service are subject to a delinquent fee of $35.00. Furthermore the unpaid balance is subject to a 1 ½% monthly (18% Annual) finance charge. If we have to submit your unpaid account to a collections process you will be responsible for all charges our practice incurs; including late fees, finance fees, collection cost, staff costs, court filing fees and reasonable attorney’s fees. Any returned checks or credit card payments will carry a $35.00 service charge.

Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns. If you have any question about our Financial Policy please consult our office staff before signing.

I have read the Financial Policy. I understand and agree to the terms of Maurice Veterinary Clinic. A picture ID is also required with
Client/Pet Owner Name
Please take a photo of your pictured ID
Pet Name
Breed
Client/Pet Owner Signature

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Date

Month Day Year
Date
Should be Empty:

MVC New Client Paperwork

Pet Information

Authorization

THE FINANCIAL POLICY OF THE MAURICE VETERINARY CLINIC

FULL PAYMENT IS DUE AT THE TIME OF SERVICE

YOUR OBLIGATION

CLIENT RESPONSIBLTY AND ADDITIONAL TERMS