New Client Appointment Request Form

WE KNOW YOUR PET’S HEALTH IS IMPORTANT AND WE THANK YOU FOR TRUSTING US TO CARE FOR THEM. TO HELP US PROVIDE THE BEST CARE POSSIBLE, PLEASE TAKE A FEW MOMENTS TO FILL OUT THIS FORM COMPLETELY. THANK YOU!

All pets MUST arrive with a secure collar and leash ( NO Flexi leads) or in carriers, or we will have to reschedule your appointment.

Wellness appointments are scheduled for 20 minutes and sick or office visits are scheduled for 30 minutes. Evaluating and obtaining records takes time away from the appointment time allotted for checking your pet in, assessing their health, and discussing findings with the doctor. Fisherville Animal Hospital Requires any and all medical records within 24 hours to allow our team to review and enter records into our system. This would also include adoption paperwork, records from a second party or breeder records. Our Email is fishervilleah@yourvetdoc.com*

I understand my appointment will be rescheduled if records are not received.I have called my veterinarian to email records over to you.I need you to call my prior VeterinarianMy pet has never seen a veterinarian or has never received any vaccinations.I will email over the medical records that I have from the shelter and/or my Vet.

Client Name (Human)*

First NameLast Name

Home Phone *

Please enter a valid phone number.

Cell Phone*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Additional Names and phone Numbers for people that you want added to the account. This allows others to bring your pet in, call for information and make decisions on pet care. *

Spouse, Family member, significant other or N/A. .

Reason for requested appointment?*

Examples: Wellness visit, Sick Visit, Just adopted a pet, Need to establish care ( meet and greet).

Pets Name *

Sex*

FemaleMaleSpayed/NeuteredUnsure

Breed of Pet*

example: Beagle, Short hair cat, Long hair cat etc...

Color of Pet*

Date of Birth or approximate age *

Name and phone number of previous veterinary hospital *

We strive to provide you with quality medicine, the time allotted to focus on your pet, and provide the communication needed to answer any questions you have about your pet. If you arrive more than 5 minutes late for your appointment, we will most likely have to reschedule you due to the limited time we have allotted to care for your pet. Our recommendation is to arrive 10-15minutes early for your appointment to assure that your pet will be seen and to allow any information still needed to be acquired. You are welcome to call the clinic at 603-229-0674 prior to your appointment to inform us if you will be late to determine if the schedule will allow your pet to still be seen or if we will need to reschedule. *

I understand that my appointment may be rescheduled to a later date.

If you would like additional pets added to your account please add them here.

N/A if you do not have any to add.

Anything you'd like us to know to help make your pet's visit stress-free?*

Example: Doesn't like paws touched, nervous, loves treats, doesn't like other animals.

Deposit Required*

A deposit will be required by end of day to schedule and/or keep your appointment or it will be cancelled.

Financial Policy*

Our Primary mission at Fisherville Animal Hospital is to deliver the best and most comprehensive veterinary care available for your pet. An important part of that mission is making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options listed below.

Payment Options.*

CashCredit Card/Debit CardCare CreditScratch Pay

I authorize the veterinarians and staff of Fisherville Animal Hospital to examine, prescribe treatment for and to perform procedures that are deemed medically necessary for the health of my pet(s). I assume all financial responsibility for charges incurred for the care of my pet(s). I understand that all charges will be paid at the time of treatment. To keep your pet protected against infectious disease and parasites, all hospitalized animals must be current on required vaccines and free of external parasites or we will treat them on admission and you will be charged for the treatment.

By signing below , you agree to the foregoing terms of payment and procedures. *

Date of signature*

Date

Once we receive all the proper paperwork and you have been added to our system you will get a phone call to schedule your appointment. This can take up to 5 business days not including weekends.

I understand that my pet may be photographed and pictures may possibly appear on www.fishervilleanimalhospital.com or Facebook and I authorize this use. (Client names will not be used in the photos)*

We love sharing your adorable pets! 🐾 With your approval, we’ll showcase their amazing personalities on our platforms. Yes, I authorize .No , I do not authorize