KVVC New Client Questionaire

Client Name

First Name Last Name

Spouse/Partner

First Name Last Name

Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Home Number

Please enter a valid phone number.

Work Number

Please enter a valid phone number.

Cell Number

Please enter a valid phone number.

Email

example@example.com

How did you hear about KVVC?

Pets:

Please list name, breed, birthday, and sex

I am the owner, or the authorized agent for the owner, of the animal(s) described above, and I hereby give the veterinarians of the Kedron Valley Veterinary Clinic, and any authorized agents, staff, or representative’s consent and authority to work on my pet(s

I understand that by signing this form today, it shall remain valid for all of my present and future pets that may be patients of the KVVC.

Signature

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Date

1205 West Woodstock Road, Woodstock, VT 05091 802 - 457 -3135
www.kedronvet.com • info@kedronvet.com

Our veterinarians at Kedron Valley Veterinary Clinic strive to provide the best services to your pets. In order to accomplish this, we require payment to be made in full at the time of service. Acceptable forms of payment include cash, check, credit/debit cards (VISA, MasterCard, Discover and American Express), and CareCredit. Unfortunately, we are unable to take post-dated checks or make individual payment plans. We can, however, help you apply for low or no interest CareCredit financing. If your pet is insured, you are still expected to pay in full at the time of service. You are then responsible for contacting the insurance company for compensation (reimbursement

Written treatment plans will be provided for all procedures except routine exams; actual costs may vary by as much as 15%. Should costs exceed the estimate by more than 15% we will attempt to contact you as soon as possible.

A 1.5% fee is charged to unpaid accounts each month. If your bill has not been settled after 3 months, we reserve the right to send your information to a collection agency.

By signing below, I understand that if there are any unpaid charges, and they are not paid per Kedron Valley Veterinary Clinic policy, I will be responsible for any collection and/or attorney fees that are incurred in attempting to collect the debt.

I have read and agree to the above Financial Policy.

Signature

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Date

1205 West Woodstock Road, Woodstock, VT 05091 802 - 457 -3135
www.kedronvet.com • info@kedronvet.com

If you plan to use KVVC for your regular veterinary care, please fill out the following form. We will ask your previous veterinarian send all medical history so that we may keep our records current.

Client Name

First Name Last Name

Spouse/Partner Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Previous Veterinarian

Pets:

I am the owner or authorized agent of the pet(s) listed above and I authorize the release of all medical records (please include all doctor’s notes). Please fax to Kedron Valley Veterinary Clinic (fax: 802-457-1264).

Signature

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Date

1205 West Woodstock Road, Woodstock, VT 05091 802 - 457 -3135
www.kedronvet.com • info@kedronvet.com

Medical Record Release