LMVC New Client Enrollment Form

Thank you for considering Little Mountain Veterinary Clinic for your pet's needs. Please fill out our new client/patient registration form in entirety to ensure we can provide you and your pet with the best possible care.
IMPORTANT:

Due to the COVID-19 pandemic, Little Mountain Veterinary Clinic is providing masks, however they are not required. Curbside service is also available for anyone who wishes.
Owner's Name*

First NameLast Name
E-mail*
example@example.com
Cell Phone Number:*
Format: (000) 000-0000.
Home Number:
Format: (000) 000-0000.
Work Number:
Please enter a valid phone number.Format: (000) 000-0000.
Address:*

Street Address

County

CityState / Province

Postal / Zip Code
Emergency Contact Information
Emergency Contact:*

First NameLast Name
Relationship*
Contact Number*
Format: (000) 000-0000.
Google (or other search engine)FacebookInstagramNextdoor.comwww.littlemountainveterinaryclinic.comSaw our hospital (location)An LMVC Team Member

Pets Information
Pets Name*
Species*
Breed*
Color*
Sex*
Age/ Birthdate*
Previous Medical Records

Cancelof
Previous Vet*
Image of your pet. *This picture will only be added to their file for our records and will not be shared with any outside parties.

Cancelof
- Additional Pets Information
- Pets Name
- Breed
- Breed
- Color
- Sex
- Age/ Birthdate
- Previous Medical Records
  
  Cancelof
- Previous Vet
- Image of your pet. *This picture will only be added to their file for our records and will not be shared with any outside parties.
  
  Cancelof

Client Policies and Procedures

We want you to be aware of and understand the following policies and procedures for all clients.
Social Media
YesNo
I agree to release Little Mountain Veterinary Clinic from all claims for libel, slander, invasion of privacy, infringement and copyright or right of publicity or any other claim and confirm that you are over the age of 18 years old. (initial below)*
Initial
Rabies Vaccination Policy
Rabies Vaccination Policy. Rabies virus is a 100% fatal disease in dogs, cats, and humans, and is endemic to North Carolina. State law mandates that all dogs and cats be up to date on their Rabies vaccination. By initialing below, you are indicating that you understand that proof of a current rabies vaccination is required for an exam. If your pet is not current on their rabies vaccination, or no proof of a current vaccination is provided, then your pet will be vaccinated at the time of exam. (initial below)*
Initial
FINANCIAL POLICY
Our office accepts Visa, Mastercard, Discover, American Express, and cash. Checks are not accepted.
Full payment is due at the time of service. This includes any charges/fees agreed to by my authorized proxy. Our team is happy to provide any client with a written treatment plan prior to services being rendered. Client will be responsible for a 5% monthly finance charge on accounts over 30 days and any collection and/or legal fees on accounts over 90 days. Your initial below indicates your agreement with these policies.*
initial
TREATMENT CONSENT
By initialing this section and signing this document, I declare I am the lawful owner of all listed pets and all information is true and correct to the best of my knowledge. I hereby authorize the veterinarian(s) of Little Mountain Veterinary Clinic to examine, prescribe for or treat the my pet(s) to the best of their abilities. I assume responsibility for all charges incurred in the care of this animal. I acknowledge that medical information will not be released to anyone not indicated on this form without my express verbal and/or written permission with the except of another veterinary facility. (initial below)*
initial
Signature*

Clear
Should be Empty:

IMPORTANT:

Pets Information

Additional Pets Information

Client Policies and Procedures

Social Media

Rabies Vaccination Policy

FINANCIAL POLICY

TREATMENT CONSENT