New Client Account Consent Form

New Client/Account Consent Form & Policies

Welcome to Highland Veterinary Clinic! In order to provide customized services for your family and your pet, the New Client Form is used to set up your communications preferences, you are attesting that you have provided accurate information about yourself and your new pet patient, will read our disclosures and our financial policies in advance, and you will be able to advise us via this form on how to best input your information and communication preferences to serve you and your pet. Once signed, this form is saved and attached as a file attachment to your first patient's chart. However, the form is not shared with any third parties beyond Highland Veterinary Clinic. Sincere completion to the best of your ability greatly decreases new client wait time during the appointment process. Please bring along a state ID for your protection, identification, and for us to maintain compliance with new prescription reporting laws--your state id is not to be listed on the new client form for your protection but is verified upon presentation and when picking up certain prescription medications.
Pet's Primary Accountholder - Full Name*

First NameLast Name
Primary Phone Number?*

Area CodePhone Number
YesNo
Pet's Second Accountholder If Applicable - Full Name

First NameLast Name
Secondary Phone Number?

Area CodePhone Number
YesNo
Any Other Adult Caregiver(s) if Any
Name(s)
Primary Accountholder E-mail (patient portal email)
example@example.com
Secondary E-mail If Desired
example@example.com
Address - Note this is your legal address where the pet is living in custody--you may add to your account an alternative mailing address if you would like, during your first appointment.*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
First Appt Date If Known

MonthDayYear
Date
Phone CallTextE-MailI am Interested in Tele-medicine Services
Household Safety:

Household health and safety is important to us - Are there any other human or pet medical alerts, dangerous allergies, behavioral health concerns, or personal safety preferences that you wish to have noted on your family’s account or pet patient's chart? If you disclose the following information to us and it will be noted as a client or patient alert on your chart (immunocompromised client, peanut allergies in the home, does not consent to anonymized pet picture on social media etc.) :
This information will be listed in the client alert section of your account or in a specific patient alert section - whichever is most applicable.
Referral
We love to acknowledge our wonderful patient families, rescues, and colleagues for positive referrals--if you were referred to our practice by a member of our pet care community or a colleague please let us know who we may thank!

Appointment Financial Considerations
Our Complete Examination Fee is $50, while Urgent Care/Extensive Exams are $65. We can provide diagnostic or treatment planning financial information beyond these fees during your visit at your request. However, it is often helpful to get a good idea of client financial expectations to minimize miscommunication and help treat all patients fairly and within reach of each families goals/budget. Do you feel you may need counseling regarding payment options on the day of your visit, or do you have an idea of your household's budget for this first visit?
CashVisa/MastercardDiscoverAmerican ExpressCareCreditScratchpay (Emergencies/Urgent Care Only)Trupanion Pet Health InsuranceOther
Financial Policies & Acknowledgements:

The next section outlines our financial policies and acknowledges that you have read these statements and understand them to the best of your ability.

I, the undersigned, assume responsibility for all charges that are incurred. I also understand that payment is due at time of release, unless other specific arrangements/agreements have been made in writing prior to treatment/services. I understand that a deposit may be required to pursue hospitalization or surgical treatment. I further understand that in the event of non-payment, fraudulent payment, bounced checks or any violation of a prior agreed payment arrangement, the entire balance shall be considered in default with the addition of any and all banking, collection fees, collection agency and/or attorney fees, necessary to the amount due to Highland Veterinary Clinic without any relief whatever from Valuation and Appraisement Laws.

I further understand that any personal checks may be presented electronically at any time for validation and deposit. I understand that the treatment of any patient will be conducted with due care and in accordance with the prevailing standards of competency in Veterinary Medicine. I certify that no guarantee or assurance has been made as to the results that may be obtained through the course of treatment undertaken by the veterinarians, agent or employees of Highland Veterinary Clinic.

I understand that a written estimate of charges is available within reasonable time at my request, that every reasonable effort will be made to operate in good faith within the confines of an estimate, but that an estimate is not a binding contract for services, and that it is my responsibility to request information regarding ongoing charges during my pet’s hospitalization.
Signature (Mouse, Touchpad, or Touchscreen Enabled)*

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Signature Name*

First NameLast Name
Date*

MonthDayYear
Date

Acknowledgement of Appointment Policy and Active Patient/Client Status
We schedule our appointments, ideally, so that each patient receives the right amount of time to be seen by our veterinarians and staff. That’s why it is very important that you keep your scheduled appointment with us, and arrive on time.

As a courtesy, and to help patients remember their scheduled appointments, Highland Veterinary Clinic sends text message and email reminders with client permissions 5 days, 2 days, and 4 hours in advance of the appointment time whenever time and scheduling permits us to do so.

If your schedule changes and you cannot keep your appointment, please contact us as soon as possible so we may reschedule you, and accommodate those patients who are waiting for an appointment. As a courtesy to our office as well as to those patients who are waiting to schedule with the physician, please give us at least 12-24 hours’ notice.
- Effective September 9, 2022 any established patient who fails to show or cancels/reschedules an appointment and has not contacted our office by phone, message, or email, with at least 24hrs notice will be considered a No Show.
- After two consecutive no-shows to your established pet’s appointment, our practice may decide apply a $25.00 “no-show” fee to your pet’s account due during your pet’s rescheduled appointment.
- If a third No Show or cancellation/reschedule with no more than 24 hour notice should occur the client account will be deactivated from Highland Veterinary Clinic and your pet’s record will be forwarded to you by email or to a different veterinarian.
- Any new client who fails to show for their initial visit may or may not be rescheduled, schedule permitting.
- As stated above, and as a courtesy, when time allows, we often make reminder texts, emails, or calls for appointments. If you do not receive a reminder call, text, or message, the above Policy will still remain in effect.
We understand there may be times when an unforeseen emergency occurs, and you may not be able to keep your scheduled appointment. If you should experience extenuating circumstances please contact our Office Manager, who may be able to waive any no-show or new client fees. We understand that life happens and our doors are always “open” via phone, text, or email. You may contact Highland Veterinary Clinic 24 hours a day, 7 days a week at the numbers below. Should it be after regular business hours Monday through Thursday, or a weekend, or should our call volume prompt you to do so, you may leave a voicemail. Messages left are recorded and time stamped in our phone system.

Highland Veterinary Clinic Phone or Text: (812) 867-6651
Email: office@highlandvet.net
I have read, understand, and acknowledge the Highland Veterinary Clinic Cancellation/No Show Policy -- Signature (Mouse, Touchpad, or Touchscreen Enabled)*

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Signature Name*

First NameLast Name
Date*

MonthDayYear
Date

Social Media Policies and Acknowledgements
Do GrantDo NOT Grant
permission to Highland Veterinary Clinic, and its agents and employees the irrevocable and unrestricted right to reproduce the photographs and/or video images taken of me, or members of my family, for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium, including but not limited to social media platforms.

I hereby release Highland Veterinary Clinic and its legal representatives for all claims and liability relating to said images or video. Furthermore, I grant permission to use my statements that were given during an interview or video blog (“vlog”) with or without my name, for the purpose of advertising and publicity without restriction. I waive my right to any compensation.
Signature (Mouse, Touchpad, or Touchscreen Enabled)*

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I, the undersigned, understand that although HIPAA (Health Insurance Portability and Accountability Act of 1996) privacy policies do not apply to veterinary patients, there are Indiana state regulatory statutes which require express written permission from a client to discuss or disclose an animal’s veterinary medical record with certain exception related to threat toward human health. I understand I may not post photos of animals which are not owned by me, nor discuss any observed animal not owned by me, nor post to social media nor correspond nor discuss verbally with a third party regarding any identified animal not owned by me that I have observed in Highland Veterinary Clinic’s facility.
Signature (Mouse, Touchpad, or Touchscreen Enabled)*

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NOMV Conduct & Anti-Bullying Clause

I agree that internet reviews are intended serve as a constructive platform to help promote excellent services, provide accurate recommendations, or improve processes which help pet owners or animal patients to receive quality veterinary services. However, I also understand and agree that Highland Veterinary Clinic’s practice owners, employees, and affiliates deserve a safe space to work with the public, veterinary clients, and to serve animals. I agree, therefore, to extend the same courtesy that Highland Veterinary Clinic extends to pet owners and will not post, nor encourage the posting of any defamatory, derogatory, threatening, nor disparaging comments, or statements about Highland Veterinary Clinic or any of its affiliates on any social media or digital platform.

If after consulting with my veterinary nursing mentor, veterinarian mentor or practice manager, and any of Highland Veterinary Clinic’s practice/business owners in an attempt to resolve any issues I may have with any client services, veterinary services, or animal care that I have provided or received at Highland Veterinary Clinic, or through its affiliates, I or an agent on my behalf still chooses to post defamatory, derogatory, threatening, or disparaging comments or statements, I waive my right to require a written release of my client/patient activities and disclosure of my own performance at Highland Veterinary Clinic. I agree that I allow any and all statements or recorded veterinary activity about my interaction with members of the staff and veterinarians, my animal(s) care and condition, at Highland Veterinary Clinic to become public or released for response within the context of said internet communications or reviews for public comment, or for legal action against me by Highland Veterinary Clinic, without any relief whatever from Indiana Veterinary Practice laws. I further understand that I will be held responsible for any/all legal ramifications stemming from my postings or internet activity regarding Highland Veterinary Clinic and it's activities with veterinary patients including, but not limited to all legal fees incurred.
Signature (Mouse, Touchpad, or Touchscreen Enabled)*

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Patient Profile Photo

Browse Files
We love to include patient profile pictures on charts--If you have a good digital photo you'd like to share, please feel free to upload it now. Cancelof
Medical Progress Photo or Video

Browse Files
If you have a photo, video, or patient chart/file which you feel is relevant to your visit today, please upload here Cancelof
Should be Empty:

New Client/Account Consent Form & Policies

Household Safety:

NEW PATIENT INFORMATION

Financial Policies & Acknowledgements:

Acknowledgement of Appointment Policy and Active Patient/Client Status

Social Media Policies and Acknowledgements