You can always press Enter⏎ to continue
Highlands Veterinary Hospital - New Client Form
  • 1

    Welcome to Highlands Veterinary Hospital

    We appreciate the opportunity to care for your pet(s). Please complete the form in its entirety.

    Press
    Enter
  • 2
    Press
    Enter
  • 3
    Press
    Enter
  • 4
    Please Select
    • Please Select
    • United States
    • 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
    • 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
    Press
    Enter
  • 5
    • Yes
    • No
    Press
    Enter
  • 6
    Press
    Enter
  • 7
    Press
    Enter
  • 8

    A deposit is required prior to medical or surgical procedures.

    Payment is required in full at the time of services. 

    For your convenience, we accept cash, Visa, MasterCard, American Express, Discover and Care Credit.

    Checks are only accepted from established clients and with prior approval. 

    Please select primary method of payment: ­
    CASH       
    DEBIT/CREDIT CARD        
    CARE CREDIT        
       By initialing here I acknowledge that I have read and agree to the cancelation policy on the reverse side of this form.

    Press
    Enter
  • 9

    I understand that I am financially responsible for all charges and am 18 years of age or older. I understand that should I default on payment of my account and collection agency services are required, all costs of collections up to 50% of the balance, including attorney/court costs will be added to the balance of my account.

    Press
    Enter
  • 10

    Cancellation  / “No Show” Policy 

    Highlands Veterinary Hospital is committed to providing all our patients with exceptional care. Due to a high demand for appointments, when a client cancels without giving advanced notice, it prevents another patient from being seen. We know life can be busy and unpredictable and there are times you are unable to keep your scheduled appointment. When this occurs, we ask the you please notify us at least 24 hours in advance, so we can offer care to another patient in need. 

    Late Cancellations: A cancellation is late when the appointment is cancelled without a 24-hour advance notice. 

    Appointment No Show Policy: A “no-show” is a client who misses an appointment without cancelling it. A failure to be present at the time of a scheduled appointment will be recorded in the patient’s chart as a “no-show”. This includes being 15 minutes late for your scheduled appointment time. 

    The first time there is a “no-show” or late cancellation there will be no charge to the client. However, if the appointment is rescheduled, we will require a $50.00 deposit for the appointment and all future appointments. If there is a second “no-show” there will be a $50.00 fee and all future visits will be on a walk-in basis and the fee for the exam will be the “walk-in” exam price of $98.00. 

    Surgery Appointment No Show Policy: A surgery "no-show" is a client who misses a surgery appointment without providing 48 hours’ notice of cancellation. The first time this occurs we will call to offer to reschedule the appointment but our missed appointment fee of $100 will be charged. If a second incident of a missed surgical appointment occurs, you will be charged our missed appointment fee of $100. Any future surgery appointment will only be scheduled if client pre-pays for the procedure desired. 

    We appreciate your understanding on this matter. Please help us to provide quality veterinary care to all clients/patients in a timely manner. If you have any questions or concerns please contact Jacki Casagranda, our Practice Manager, at 406-299-3700.

    Press
    Enter
  • 11
    -
    Pick a Date
    Press
    Enter
  • 12
    Clear
    Press
    Enter
  • Should be Empty:
Question Label
1 of 12See AllGo Back
close