New Client Intake Form

New Client Form
Primary Contact*

First NameLast Name
Primary Phone Number*
Please enter a valid phone number.
Is this a cell phone or landline number?
Physical Address*

Street Address - Please do not list PO Box

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Email*
example@example.com
Who was your previous family veterinarian? *
*We will call for your pets records*
Secondary Contact Information
Would you like to add a secondary contact to your account?*
Note: The secondary contact will be financially responsible for all charges incurred in the event FurWell Animal Hospital cannot reach the primary contact.
Secondary Contact Full Name

First NameLast Name
Secondary Contact Primary Phone Number
Please enter a valid phone number.
Secondary Contact Email
example@example.com
Referral Information
Were you referred to FurWell Veterinary Hospital by a current client?*
Family/Friend who referred you?

First NameLast Name
Phone number of referring family/friend
Please enter a valid phone number.
If making a future appointment for one of your pets please let us know who the appointment is for and what we will be seeing them for.
FurWell Veterinary Hospital values clients who refer us to their friends and family, as well as those who have been referred to our practice. This allows us to continue to grow in our community and maintain the highest reputation for being one of the best in the business. We want to thank you for your continued support by giving you $25 off your next bill. In addition, we will also be giving $25 credit to the pet parent who sent you our way!

Client Authorization & Financial Agreement
I hereby confirm that all information provided above is accurate to the best of my knowledge. I authorize the veterinarians of FurWell Veterinary Hospital locations to examine, prescribe for, and/or treat my pets as deemed necessary.

I understand that I am financially responsible for all charges incurred for the care of the pets listed on my account. Payment in full is required at the time services are rendered or upon patient discharge. A reservation fee may be required prior to treatment, depending on the nature of the services.

For the safety of all patients, clients, and staff, all pets must be properly restrained either in a carrier, on a leash, or with a harness when entering or leaving the hospital.

If same-day medical care is required for an unexpected illness or condition, additional fees will apply ($125 same day/work-in).

Reservation Fee Policy
A $100 reservation fee is required for all new clients and multi-pet appointments.

A $300 reservation fee is required for all initial TCVM consultations with Dr. Barr.

This fee confirms and secures your appointment time, helping to reduce late cancellations and no-shows. It is not an additional charge and will be credited toward your visit. However, the fee is non-refundable if you cancel within 24 hours of your appointment or fail to arrive.

Reservation fees can be paid via a convenient text-to-pay link. Once you and your pet are established clients, you will no longer be required to pay a reservation fee for future visits unless you cancel within 24 hours or do not show for your appointment.

If two late cancellations or no-shows occur after becoming an established client, a reservation fee will be required for all future bookings. Exceptions for emergencies or unforeseen circumstances may be considered by management on a case-by-case basis.

All surgical procedures require a $350 reservation fee before scheduling.

Payment Options Notice
Effective October 16, 2025, FurWell Veterinary Hospital(s) will offer dual pricing for all services:
- Card price
- Cash price
Client Signature*

Clear

Pet(s) Information
Pet #1 Name*
Breed*
Color*
Sex*
Are they spayed or neutered?*

YesNo
Estimated Birth Date*

MonthDayYear
Current Medication(s)*
Please list name and dose of medication, including current heartworm & flea/tick prevention.
We'd love to see a photo of your pet! (Any photo you upload of your pet is for in-clinic use only and will not be shared)
Any Additional Pet's You Would Like to Add to Your Account? *

Pet #2 Information
Pet #2 Name
Breed
Color
Sex
Estimate Birth Date

MonthDayYear
Current Medication(s)
Please list name and dose of medication, including current heartworm & flea/tick prevention.

Pet #3 Information
Pet #3 Name
Breed
Color
Sex
Estimated Birth Date

MonthDayYear
Current Medication(s)
Please list name and dose of medication, including current heartworm & flea/tick prevention.

Do you give FurWell Veterinary Hospital permission to use photos of your pet(s) taken in clinic on their social media pages?*

YESNO
Client Signature*

Clear
Should be Empty:

New Client Form

Secondary Contact Information

Referral Information

Pet(s) Information