Today’s Date
/
Month
/
Day
Year
Reason for form
New Client
New Pet
Personal Info Update
Owner's Name
Spouse/Other
Street Address
City
State
Zip
Primary Phone
Format: (000) 000-0000.
Accept Texts At Primary Phone Number?
Yes
No
Use secondary phone number for texts
Secondary Phone #
Primary Owner's Employer
Spouse/Other employer
Driver’s License # (if paying by check)
Primary Owner’s DOB
Spouse/Other's DOB
Preferred email address
example@example.com
We prefer to send receipts/report cards/information via email is this ok or do you prefer a printed copy?
Printed Copies Requested
Email is ok
Pet #1 Name
Pet #1 Species
Cat
Dog
Other
Breed
Age or Date of Birth if known
Color
Sex
Male
Female
Spayed/Neutered
Unknown
When were the last vaccines given (if applicable) and what was given?
What heartworm/flea/tick prevention is given?
Has the pet ever been tested for heartworm, ticks, or leukemia (cats)
Yes
No
Unknown
Current Medical Conditions
What is your main purpose for today’s visit?
NEW CLIENTS: How did you find out about us?
What is your preferred method of payment today?
Credit Card (Visa, Mastercard, Discover, Apple Pay, etc)
Check
Cash
Care Credit
Scratch Pay
To help prevent the spread of infectious and zoonotic diseases within MVVC— all hospitalized and surgical pets must be current on all required vaccinations. State Law requires all pets to have minimum RABIES vaccination. +I understand every effort will be made to achieve a successful outcome for my pet, and to provide for all possible in safety in hospital care and handling. I hereby authorize this clinic to receive, prescribe for, treat, or perform surgery upon the pet listed above and additional pets I present. I understand that veterinary service may be provided during night time hours while hospitalized under the judgement of the DVM. I understand MVVC is not a 24 hour care center. Please Initial Below
I hereby agree to pay my account as services are rendered. If for any reason a balance is owed on my account, a $5 monthly billing fee and 1.5% monthly interest may be added if prompt payment is not paid upon receipt of statement. I understand that responsi- bility for the payment for services provided in this clinic is mine due and payable at the time services are rendered or product is bought. In the event of default, I am liable to pay such collection costs, including any certified mailings and reasonable attorney fees as may be required to effectively collect the debt. In the event that a check is returned due to insufficient funds, a $25 fee will Please Initial Below
Do you require an estimate of today’s services prior to seeing the doctor?
Yes
No
SIGNATURE
*
IF NO OTHER PETS TO ENTER SCROLL TO BOTTOM TO SUBMIT
Pet #2 Name
Pet #2 Species
Cat
Dog
Other
Breed
Age or Date of Birth if known
Color
Sex
Male
Female
Spayed/Neutered
Unknown
When were the last vaccines given (if applicable) and what was given?
What heartworm/flea/tick prevention is given?
Has the pet ever been tested for heartworm, ticks, or leukemia (cats)
Yes
No
Unknown
Current Medical Conditions
Pet #3 Name
Pet #3 Species
Cat
Dog
Other
Breed
Age or Date of Birth if known
Color
Sex
Male
Female
Spayed/Neutered
Unknown
When were the last vaccines given (if applicable) and what was given?
What heartworm/flea/tick prevention is given?
Has the pet ever been tested for heartworm, ticks, or leukemia (cats)
Yes
No
Unknown
Current Medical Conditions
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