Welcome to BVVC
Blanchard Valley
Veterinary Clinic
Name
*
Date
*
/
Month
/
Day
Year
Date
Address
*
City
*
State
*
Zip
*
Email
*
example@example.com
Home Phone
Cell Phone
Work Phone
Emergency Contact Name and Phone Number
*
Spouse
Cell
Work
Preferred Method of Contact
*
Text
Email
Phone
How did you learn about our clinic? Referral
*
Website
Social Media
Phone Book
Location
Word Of Mouth
Other
Back
Next
Pet Information
Name
*
Pet Information
*
Dog
Cat
Other
Birthday/Age (Best Guess)
*
Breed(s)
*
Color
*
Sex
*
Male
Female
Neutered/Spayed
*
Yes
No
If so, at what age?
Are they on a diet/What food are they given
*
How long have you had your pet?
Where did you get your pet?
Has your dog been vaccinated?
*
Rabies
DA2PP
Lepto
Kennel Cough
Lyme
Other
Has your cat been vaccinated?
*
Rabies
FVRCP
FeLV
FIV
Other
Has your pet had any reactions?
Anesthesia
Vaccines
Medications
Flea Meds
Other
Back
Next
Payment
We will gladly prepare a written estimate for any services as requested and require you to sign an estimate for all services over $250. All payments are due in full at the time services are provided. We accept Visa, MasterCard, Discover, CareCredit, cash, and checks. A service charge will be added for all returned checks and accounts turned over to a collection agency.
Owner Signature and Consent
To prevent the spread of infectious diseases, all hospitalized patients are generally required to be current on all recommended vaccines, and free from internal and external parasites. A signature below acknowledges that you have been informed of this information, have consented to have us care for your pet, and have consented to us obtaining/sharing needed veterinary records to/from other clinics which care for your pets.
Signature of Owner or Responsible Agent
*
Date
*
/
Month
/
Day
Year
Date
Please verify that you are human
*
Submit
Should be Empty: