Belton New Client Form

Thank you for choosing us for your pet’s veterinary services.
Please help us to better serve you by completing this form in its entirety.

DATE OF APPOINTMENT*

Date

Name*

First NameMiddle InitialLast Name

PREFERRED PRONOUN

He/Him/HisShe/Her/HersThey/Them/Theirs

CELL PHONE #*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

EMAIL ADDRESS*

example@example.com

Spouse Name

First NameMiddle InitialLast Name

PREFERRED PRONOUN

He/Him/HisShe/Her/HersThey/Them/Theirs

SPOUSE CELL PHONE

SPOUSE EMAIL

HOW DID YOU LEARN ABOUT OUR CLINIC?

NAME OF PET*

TYPE OF PET*

DOGCAT

SEX*

BREED*

COLOR*

BIRTHDATE OR AGE*

VACCINE HISTORY (IF NOT AT THIS CLINIC)

REASON FOR VISIT*

FOR ADDITIONAL PETS: PUT NAME, SEX, BREED, COLOR, AGE, & WHETHER SPAYED/NEUTERED

Acknowlegement of non-refundable booking deposits and payment:

In order to reduce no-shows and ensure that we maximize appointments times for our patients in need, we require a non-refundable booking deposit of $60 for all new clients in order to schedule their first appointment. The booking deposit is not an additional fee: it is applied to the total of your visit, and any remainder is due at check out. The deposit is non-refundable: it is kept as a missed appointment fee if the client no-shows, cancels, or reschedules less than 12 hours in advance of the appointment time, and a new deposit is required for the next appointment. The deposit is transferrable to an appointment that is rescheduled at least 12 hours in advance.

The $60 booking deposit will also be made required for established clients that no-show a scheduled appointment. Repeat no-shows will require permanent prepayment in order to schedule.

There is a minimum $100 non-refundable booking deposit for all surgery appointments: this will also be applied to the visit total, or kept as a missed appointment fee if the client no-shows, cancels, or reschedules less than 24 hours before the scheduled appointment time. The deposit is transferrable to a surgery appointment that is rescheduled at least 24 hours in advance.

For hospital admission and urgent care treatment, we require all clients provide payment of 50% of the upper estimate before starting treatment. The remainder is due at the time of discharge, and any unused portion will be refunded.

All payment is due at the time of service: the option we have for our clients to pay their bill in payments is CareCredit, a medical credit card that allows clients to pay interest-free over 6 months on bills over $199, as long as the minimum payment is made on-time. More information can be found at CareCredit.com We also accept all major credit cards, and recommend pet insurance for all clients in order to make pet care expenses more manageable. Due to the CareCredit terms of service, CareCredit can not be used for booking deposits, but at check out we can refund the booking deposit to the original form of payment and add the $60 to the total for a single CareCredit bill.

By signing below, you acknowlege the policy on booking deposits as outlined above.

SIGNATURE*

Clear

DATE OF SIGNATURE*

Date

METHOD OF PAYMENT

PET HEALTH HISTORY

AUTHORIZATION