Dallas Veterinary Clinic - New Client Application

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Does your pet have an urgent need to be seen by a DVM in the next 2 business days?* This field is required.
YESNO
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Please let us know what your pet needs to be seen for. * This field is required.
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Name* This field is required.
Dr.
Dr.
Mr.
Mrs.
Ms.
Prefix
First Name
Last Name
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Spouse/Partner
First Name
Last Name
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Address* This field is required.
Street Address
Street Address Line 2
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Country
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Contact Information* This field is required.
Home Phone Number
Work Phone Number
Mobile Phone Number
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Email* This field is required.
example@example.com
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Emergency Contact Name * This field is required.
First Name
Last Name
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Emergency Contact Phone Number* This field is required.
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Emergency Contact Email* This field is required.
example@example.com
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* This field is required.
Previous Veterinarian
Previous Veterinarian Phone Number
Previous Veterinarian Email
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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?
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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
Social Media
Referral
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.
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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 and does not offer financing or payment plans. 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
We require the completed new client application and any prior veterinary records in order to book an appointment for new clients. We require all new clients to have an updated and valid credit card on file and we take pre-payment for the NON-REFUNDABLE $89 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* This field is required.
Please initial that you have read and agree to the statement above
35
I understand that Fear Free Visits are additional $29 charge at sole discretion of DVM or practice owner for 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 *
36
Appointment Type

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 you pick up your pet after closing hours, DVC no longer boards pets overnight and I understand and agree that I will be charged $100 per night to cover expenses of bringing in a caregiver for my pet in the event I am not able 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. I also understand and agree to check back as policies may be updated from time to time.
37
Upload Records
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Cancelof
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It's urgent and needs seen in 24-48 hrs* This field is required.
Yes
No
39
Why?
40
what is purpose of 1st visit with us?
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Signature* This field is required.
Clear
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Date* This field is required.
Date
Year
Month
Day
Should be Empty:

Appointment Type