New Client Form

Owner Name*
First and Last Name
Street Address*
City, State, Zip Code*
Email
example@example.com
Phone Number*
Emergency Contact Name
First and Last Name
Emergency Contact Phone Number
Previous Vet Records

Please provide our office with your pet's previous history 24 hours prior to your appointment. Please email their records to us at info@cahwaller.com. Let us know if you need assistance getting your records and we will attempt to retrieve them on your behalf.
Previous Veterinary Hospital
Previous Vet Phone Number
How did you learn about our clinic?
If recommended, by whom?
Pet's Health History
Name of Pet
Species?

DogCat
Breed of Pet
Pet's Color
Pet's Gender

FemaleMaleMale NeuteredFemale SpayedUnknown
Is your pet currently on any medication?
If yes, what medications?
Describe your pet's diet?
Consents
Do we have your permission to post pictures of your pet(s) on social media?

YesNoContact me first
Can we release your medical records? - I authorize Companion Animal Hospital of Waller to release my pet's medical records as requested to other veterinarians and/or boarding and grooming facilities.

YesNo
NO SHOW & LATE POLICY

Late Arrival Policy: We make every effort to be on time for all our appointments. Unfortunately, when even one patient arrives late, it can throw off the entire schedule for that day. In addition, rushing or “squeezing in” an appointment shortchanges the patients and contributes to decreased quality of care. Therefore, a client that arrives 15 minutes or more late to their scheduled appointment will be rescheduled. We apologize for any inconvenience this might cause.
Cancellation of an Appointment: In order to be respectful of the medical needs of other patients, please be courteous and call our office promptly if you are unable to show up for an appointment. If it is necessary to cancel your scheduled appointment, we ask that you call at least 24 hours in advance. Appointments are in high demand, and your early cancellation will allow another patient access to timely veterinary care. If it is after hours, please leave a message on the voicemail or email info@cahwaller.com
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”.

The first time there is a “no show”, we will contact you via phone/mail/email to inform you of the missed appointment and remind you of our “no show” policy. You will be required to pay a nonrefundable prepayment of $25 for the rescheduled appointment.

A 2nd occurrence will result in no refund of the $25 deposit. You will be able to reschedule one final prepaid appointment at an additional $50.

The 3rd occurrence within one year will result in you being discharged from the practice and the second $50 deposit will not be returned.
By submitting this form, I assume responsibility for all charges incurred in the care of this animal. I understand that full payment for charges is due at the time of release and that a deposit may be required for surgical or medical treatment. If there is a credit card number on file, I give authorization to charge my card. If my pet is brought into the clinic on an emergency basis, I authorize all care to preserve the life of my pet and to minimize suffering. Further, I understand Companion Animal Hospital of Waller will from time to time photograph or videotape work in progress at our facilities for educational, training, promotional, and/or other purposes. This serves as notification that your pet may appear in such photos and/or videotapes, that Companion Animal Hospital of Waller has permission to use them, and there will be no compensation for such usage.
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Previous Vet Records

Pet's Health History

Consents

​NO SHOW & LATE POLICY

NO SHOW & LATE POLICY