New Client Request Form

Thank you for giving the Point Breeze Veterinary Clinic the opportunity to care for your pet.

Once this form has been received, we will contact you to set up an examination for your pet(s).

Please take the time to read this form in its entirety. Thank you!

I understand that in order to schedule an appointment as a new client, I must pay a scheduling fee of $86 per pet at the time of scheduling. This fee will be applied as a credit towards my first appointment. Initials:*

I understand that I must complete the welcome sheet and provide the Point Breeze Veterinary Clinic with my pet's previous history. I furthermore understand that if I have failed to do so at least 24 hours in advance of my pet's appointment, the appointment is subject to cancellation without notice. Initials:*

I understand that failure to provide 24 hours notice to reschedule or cancel my pet's appointment will result in the closure of my account at the Point Breeze Veterinary Clinic, and I will not be able to seek care here in the future. Furthermore, I understand that the scheduling fee of $86 per pet will not be refunded. Initials:*

I hereby authorize the veterinarians to examine, prescribe for, and otherwise treat my pets. I assume responsibility for all charges incurred in the care of these animals. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment.

Signature*

Today's Date*

Date

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Preferred method of communication from the office:*

Phone CallTextEmail