VCPI Client/Patient Information Form

Client/Patient Information Form

Today's Date *

Date

Your Name *

First Name Last Name

Address *

Phone *

Email *

example@example.com

Name *

Age *

Years Months

Species *

Breed *

Color *

Sex *

AUTHORIZATION & FINANCIAL RESPONSIBLITY

I am the owner of the above animal or am responsible for it, am 18 years of age or older, and have the authority to execute this consent and hereby authorize Veterinary Center of Parker, Inc. after consultation with me to administer treatments and perform procedures that are necessary for the well-being and care of the Pet. I understand that there are no guarantees associated with any treatments and procedures.

I assume personal financial responsibility and agree to pay for all charges and expenses invoiced at time of service. I agree to pay a recurring 1.5% per month interest on any amounts unpaid after 30 days, a $40 service charge for each NSF check, and any and all costs and expenses, including legal fees, for collection of any and all unpaid amounts.

Payment is required at time of service. For your convenience, we accept Visa, MasterCard. Discover, American Express, Care Credit, Cash or Check. We also accept PayPal payments via our website @www.vcparker.net.

Ifl neglect to pick up the pet within five days of written notice, sent to the above address, my pet will be considered abandoned. In cases of abandonment, Veterinary Center of Parker, Inc. will have authorization to take care of the pet as seen fit. Abandonment does not release me from my obligation to pay for all charges involved.

I agree to the Authorization & Financial Responsibility Policy Explained Above (Your Initials) *

Type Your Initials

RECORDS RELEASE

I hereby give Veterinary Center of Parker, Inc. its representatives and employees permission to send my pet's records as needed to other clinics and facilities.

I agree to the Records Release Policy Explained Above (Your Initials) *

MEDIA RELEASE

I hereby give Veterinary Center of Parker, Inc. its representatives and employees the right to take photographs and videos of me and/or my pet, and to copyright, use and publish the same in print and/or electronically. I agree that Veterinary Center of Parker, Inc. may use such photographs/videos of me and/or my pet with or without my pet's name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, social media and Web content.

I understand my pet's image may be edited, copied, exhibited, published or distributed and waive any right to royalties or other compensation arising or related to the use of my pet's image or recording.

I agree to the Media Release Policy Explained Above (Your Initials) *

Type Your Initials

24 HOUR CANCELLATION, NO SHOW AND LATE FEE POLICY

We require 24 hours notice to cancel/reschedule any scheduled appointment.

Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. Therefore, Veterinary Center of Parker, Inc. has the following policies:

NO-SHOW = If an appointment is missed without 24 hours notice:
- There will be a non-refundable no-show fee of $75 for surgical appointments.
- 1st No-Show- we will call and inform you that your appointment was missed and explain our no-show policy again.
- 2nd No-Show- We call you to inform you that your appointment was missed, we will work with you to re-schedule your appointment and we will require that you pre-pay the exam fee for that next appointment at time of rescheduling.
- 3rd No-Show- We reserve the right to apply your pre-paid exam fee as a no-show fee, we will call to inform you that your appointment was missed for a third time and we will proceed with termination from the practice.

LATE ARRIVAL = Arriving 5 Minutes Past Your Scheduled Appointment Time:
- If you arrive 5 minutes past your scheduled appointment time, a $15 delayed fee will be assessed as this puts our staff and the rest of our appointments behind.
- After 10 minutes, we will mark the appointment as a no-show and proceed with our no-show policy.
- If you show up for your appointment after 10 minutes, we will discuss with our technical staff if we are able to still work you in as we will then be behind in our schedule. If we can work you in, there will be a $30 work-in fee assessed.

I agree to the 24 Hour Cancellation, No Show and Late Policy Explained Above (Your Initials) *

Type Your Initials

You can schedule/change an appointment from our App, your Pet Portal or call to speak with a Client Care Representative at 720.851.0820.

Thank you for your understanding and cooperation as we strive to best serve the needs of all of our patients.

Signature *

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Pet Information