Twin Maples Veterinary Hospital

New Client and Pet Information Form

Welcome to Twin Maples Veterinary Hospital. So that we may serve you better, please complete the following:
Client Information
Home Phone Number
(This number will be used as your account number)
Owner's Name

First NameLast Name
Spouse/Co-owner Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone Number
(include extension, if needed)
Cell Phone Number
Spouse/Co-owner Work Phone Number:
Spouse/Co-owner Cell Phone Number
Please enter a valid phone number.
Email
example@example.com
Would you like your reminders to be sent by

TextEmailMail
How did you first hear of us?
Word of mouth? Google? Yelp? Yellow Pages? etc...
New Pet Information
Pet's Name
Species

DogCatOther
If Other, enter species here
Breed
Sex

MaleFemale
Neutered/Spayed

YesNo
Coat color(s)
Age (Date of birth, if known)
Previous Veterinary Hospital
Doctor Preference
Does your pet have an appointment?

YesNo
If so, what day/time?
If your pet has had previous vaccines, please bring the records to the appointment, or fax records to 937-866-5917
Financial Policy

I understand that FULL PAYMENT IS REQUIRED AT THE TIME OF SERVICE and a deposit may be required for any hospitalized. Accepted forms of payment are Cash, Check, MasterCard/Visa, Discover card, American Express, Care Credit and Scratch Pay. All unpaid balances are subject to 1.5% per month interest charge. Returned checks are subject to the incurred returned check fee. In the even legal action is required to recover an unpaid balance I agree to pay all interest, court costs and attorney’s fees. After 60 days of nonpayment on the account Twin Maples may relinquish your balance owed to a collection agency.
Date

MonthDayYear
Date
Client/Owner Birthdate

MonthDayYear
Date
Client/Owner Signature

Clear
No Show/Cancellation Policy

As a client of Twin Maples we ask that you follow these attendance guidelines
- Please give at least 24 hour notice for cancellation. If you are unable to give a 24 hour notice please contact our office as soon as possible via call or text. Cancellations for emergencies or unexpected events will be handled on an individual basis.
- If you do not call/text prior to 24 hours or do not arrive to your appointment, you are considered a no-show. Multiple no-shows (3 doctor appointments or 2 surgical appointments) may result in DISMISSAL from Twin Maples and transitioning your pet’s care to another veterinary office.
- If you are 15 minutes late, your appointment will likely be rescheduled. If we are able to accommodate you, patients who arrive on time will be seen ahead of you. This may also result in an additional fee to the regular exam fee. If you are going to be late, Please contact the office as soon as possible so that we may determine if your appointment can still be accommodated. Frequently arrive 15 minutes or later may result in DISMISSAL from Twin Maples and transitioning your pet’s care to another veterinary office.
Date

MonthDayYear
Date
Client/Owner Birthdate

MonthDayYear
Date
Client/Owner Signature

Clear
By submitting this form, you are accepting financial responsibility for this pet.
Should be Empty:

New Client and Pet Information Form

Client Information

New Pet Information

No Show/Cancellation Policy