Dallas Veterinary Clinic - New Client Application

1
Does your pet have an urgent need to be seen by a DVM in the next 2 business days?* This field is required.
YESNO
2
Please let us know what your pet needs to be seen for.* This field is required.
3
Name* This field is required.
Mr.
Mr.
Dr.
Mrs.
Ms.
Prefix
First Name
Last Name
4
Spouse/Partner
First Name
Last Name
5
Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Contact Information* This field is required.
Home Phone Number
Work Phone Number
Mobile Phone Number
7
Email* This field is required.
example@example.com
8
Emergency Contact Name * This field is required.
First Name
Last Name
9
Emergency Contact Phone Number* This field is required.
10
Emergency Contact Email* This field is required.
example@example.com
11
* This field is required.
Previous Veterinarian
Previous Veterinarian Phone Number
Previous Veterinarian Email
12
Pet Information* This field is required.
Pet's name
Please Select
Please Select
Dog
Cat
Species
Breed
Color
Date/Place of Last Vaccinations
Date of Birth
Please Select
Please Select
Male
Female
Gender
Please Select
Please Select
Yes
No
Is your pet neutered/spayed?
13
Please describe any chronic health problems (kidney disease, heart condition, diabetes, etc.)* This field is required.
14
Medication and/or special diet* This field is required.
15
Is your pet allergic to any medication or has your pet ever had allergies or an allergic reaction? Please describe* This field is required.
16
Add a 2nd pet?* This field is required.
Yes
No
17
#2 Pet Information* This field is required.
Pet's name
Please Select
Please Select
Dog
Cat
Species
Breed
Color
Date/Place of Last Vaccinations
Date of Birth
Please Select
Please Select
Male
Female
Gender
Please Select
Please Select
Yes
No
Is your pet neutered/spayed?
18
Please describe any chronic health problems (kidney disease, heart condition, diabetes, etc.)* This field is required.
19
Medication and/or special diet* This field is required.
20
Is your pet allergic to any medication or has your pet ever had allergies or an allergic reaction? Please describe.* This field is required.
21
Add a 3rd pet?* This field is required.
Yes
No
22
#3 Pet Information* This field is required.
Pet's name
Please Select
Please Select
Dog
Cat
Species
Breed
Color
Date/Place of Last Vaccinations
Date of Birth
Please Select
Please Select
Male
Female
Gender
Please Select
Please Select
Yes
No
Is your pet neutered/spayed?
23
Please describe any chronic health problems (kidney disease, heart condition, diabetes, etc.)* This field is required.
24
Medication and/or special diet* This field is required.
25
Is your pet allergic to any medication or has your pet ever had allergies or an allergic reaction? Please describe.* This field is required.
26
Who is authorized to drop-off/pick up or request services for your pet (children/parents/grandparents/friends)?* This field is required.
27
How did you learn of our practice?* This field is required.
Drive by
Referral
Google Search
Instagram
Facebook
Nextdoor
Other
28
Please describe (ie: facebook, instagram, nextdoor. specific post that caught your attention?)
29
If Referral, who we can thank for referring?* This field is required.
30
If Other, Please specify* This field is required.
31
I grant permission to have my pet(s) photo (pet name only) on social media/DVC website.* This field is required.
Yes
No
32
I understand DVC is NOT a low cost clinic, does not offer financing, payment plans, adn we do not accept Care Credit or Scratchpay. I promise to take full responsibility for and pay in full for ALL costs incurred in treatment of my pet(s) AT TIME OF SERVICE* This field is required.
Please initial that you agree
33
I have reviewed DVC's core values, I agree and my values are in alignment with them.* This field is required.
34
I have read and agree with DVC's core values and Policies, and I am in agreement as evidenced by my signature on this application, and this agreement extends to whomever I send to request goods and services for my pet.* This field is required.
Clear
35
We require the completed new client application and any prior veterinary records in order to book an appointment for new clients. We require all clients to have an updated and valid credit card on file in our secured payment system and we take pre-payment for the NON-REFUNDABLE $90 exam/consultation fee to schedule an appointment.

I understand and agree that if I arrive to the appointment and disagree with DVC's policies or change my mind and refuse services, the consult/exam office visit fee is still non-refundable.

Please note: Payment is due in full at time services are rendered. We accept all major credit cards. We do not accept Scratchpay, CareCredit, or any financing or payment plans.

All services and goods are non-returnable/non-refundable, except prescription diet food purchased from us in the prior 30 days for which credit to DVC account may be applied upon return of unused food.

I agree to have my card saved in DVC's secure payment system and authorize charges for goods and services requested for my pet(s).

Please initial that you have read and agree to the statement above *
36
I understand that Fear Free Visits are an additional $29–$69 charge at the sole discretion of the DVM or practice owner's evaluation of the pet's Fear and Anxiety score at each visit (which may vary), and highly skilled expertise, time, and/or other professional services associated with offering a Fear Free experience, based on our professional observation and evaluation of all pets brought into the practice, and I hereby agree.
I Agree *
37
Appointment Types

Curbside Appointment:

Please remain in the parking lot for the duration of your pet's appointment. Please keep your phone charged and available so the Doctor or Technician can reach you to discuss your pet's appointment and any treatment plans and instructions.

Inpatient Care Appointment:

Inpatient care fee for well visits is $20, any stays over 2 hours will incur a $82 hospitialization fee. Your pet must be picked up by 5:30pm on weekdays, or by 12pm on Saturdays. If I pick up my pet after closing hours, I understand that DVC no longer boards pets overnight. I agree to be charged $100 per weeknight and $300 for Friday, Saturday and Sunday nights, as well as on or before major holidays or other days when DVC is closed, to cover the cost of bringing in a caregiver in the event I am unable to pick up my pet before closing time. By signing below, I acknowledge that I have read and understand DVC's policies as posted on dallasvet.net and agree with them.

In Person

We welcome you and your family (furry and human) into our calm, clean and comfortable environment. Aromatherapy is flowing, sound machines whispering, calming pheromones clearing the air, clean comfy pet beds and pillows are fluffed; your comfort is a priority here!
38
Upload Records
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
39
It's urgent and needs seen in 24-48 hrs* This field is required.
Yes
No
40
Why?
41
what is purpose of 1st visit with us?
42
Signature* This field is required.
Clear
43
List the names of any people you authorize to approve services or purchases for your pet, and describe their relationship to you (for example: spouse, child, parent, assistant, nanny, pet sitter).
44
Date* This field is required.
Date
Year
Month
Day
Should be Empty:

Appointment Types