VEC New Client Form

VEC New Client Form
Owner's Information
Primary Owner's Name*

First NameLast Name
Secondary Owner's Name (If Applicable)

First NameLast Name
Have you been to either the Veterinary Emergency Center OR Leshem Veterinary Surgery with any animal in the past?*

Yes, I'm a returning client.No, I have never been to this facility before.
How did you hear about the Veterinary Emergency Center?*
Please select one
Where did you hear about us?

Returning clientReferral from VeterinarianInternet SearchGoogle/Social mediaFamily/FriendDrive By/SignOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Please enter a valid phone number that is able to send and receive text messages.
Alternative Cell Phone Number
Please enter a valid phone number that is able to send and receive text messages.
Email*
example@example.com
Driver's License Number *
Issuing State of Driver's License*
Do you have a primary veterinary practice?*

YesNo
Please provide the name of your primary veterinary practice. Write "None" if you do not have one.*
Have you or anyone in your party had any recent exposure to, or symptoms of, Covid?

YesNo
Animal's Information
Animal's Name*
Species*
Breed/Type (write "unknown" if unsure)*
Color*
Sex*

MaleFemaleUnknown
Spay or Neuter Status*

Animal is Spayed/NeuteredAnimal is NOT Spayed/NeuteredUnknown
Age or Birthday*
Briefly describe reason for today's visit*
More details will be gathered by our veterinary team upon presentation.
Does your pet show and anxiety or aggression at the vet?*

YesNoUnknown
If your pet DOES have anxiety at the vet, does he/she need a muzzle for exam?

YesNoUnknown
Is your pet up to date on his/her rabies vaccine?*

YesNoUnknown
Please be aware that VEC is an urgent care facility, not a 24-hour ER. While we do have overnight nursing care, a veterinarian is not always on site. Depending on the severity of the case, you and your pet may be referred elsewhere for further care at our doctor's discretion. Referrals are recommended with the best interest of your pet in mind.*

I have read and acknowledged the statement above.
As an urgent care facility we may, and typically do, have a wait. VEC sees patients in order of the most critical case first. We are not first come, first serve. If a newly arrived patient is seen by the doctor before your pet, please understand this is for an important, and possibly life-threatening, reason.

All dogs must be leashed and cats and small mammals must be secured in a carrier.

If an exam room is not available, a nurse may elect to bring your animal directly into the treatment area for the doctor to examine while you remain in the lobby. Discussions with the attending veterinarian regarding findings, recommendations, and estimated costs will then take place before any treatments or diagnostics are performed.
Please sign to acknowledge that you have read and understand the statement above. *

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VEC's initial exam fee is $170, and full payment is due for all costs at the time of services rendered. We do not offer payment plans.

We accept most forms of payment including CareCredit and Scratchpay, but do not accept checks.

Any verbal estimates provided to you by a staff member are binding and must be honored fully.

Finally, the Veterinary Emergency Center does reserve the right to refuse service for any reason.
Please sign to acknowledge that you have read and understand the statement above.*

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Date*

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VEC New Client Form

Owner's Information

Animal's Information