Muller Veterinary Hospital Registration Form

  • Registration

  • Have you ever brought a pet to Muller Veterinary Hospital before?*
  • Owner Date of Birth (for DEA prescription reporting purposes)*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Is There a Spouse/Partner/Family Member Who Should Be Listed On Your Account?
  • Format: (000) 000-0000.

  • In case of emergency...

  • Is there anyone else over the age of 18 (besides above listed contacts) who should be listed on your account, who has ongoing permission to make medical decisions for your pet(s)?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • How did you hear about us?*
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  • Species*
  • Sex*
  • Is Your Pet Microchipped?*
  • Do You Already Have a Scheduled Appointment?*
  • Appointment Date
     - -
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  • Do You Have Pet Insurance?

  • If yes, please write in the company name, and sign below authorizing us to release any medical records requested by your insurance company.       

  • Do You Have More Than One Pet At Home?*
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  • Species*
  • Sex*
  • Is Your Pet Microchipped?*
  • Do you have more than 2 pets at home?*
  • Browse Files
    Drag and drop files here
    Choose a file
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  • Species*
  • Sex*
  • Is Your Pet Microchipped?*
  • Do you have another pet at home?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Species*
  • Sex*
  • Is Your Pet Microchipped?*

  • This form supports telling us about 4 pets in your home. If you have more than 4 pets, please let our office know and we will happily collect information to add them to your account. 

  • Client Policies and Procedures

    Our goal is to provide quality individualized veterinary care to our patients in a timely manner. Missed appointments, late cancellations and late arrivals inconvenience those patients who need access to veterinary care. We want you to be aware of and understand the following policies and procedures for all clients.

  •  Cancellation/Missed Appointment Policy

    We see patients on an appointment only basis. This ensures that we are able to provide appropriate care to all of our patients. In order to be respectful of the medical needs of other patients, please be courteous and call our office promptly if you are unable to show up for an appointment.

    Appointments are in high demand, and your early cancellation will allow another patient access to timely veterinary care. We require that you call at least 2 business days in advance to reschedule  or cancel your appointment in order to avoid a late cancellation fee. Appointments made within 2 business days of the appointment date and time are still subject to this fee.  Missed appointments will also result in a fee. Missed or late cancel fees are not covered by pet insurance companies.

    Cancellation/Missed Appointment Policy for Procedures/Surgeries

    Due to amount of time needed for procedures and surgeries we ask that you cancel or reschedule at least 3 business days in advance so that the time can be reallocated to a patient who is in need of treatment. Failure to cancel at least 3 business days in advance may be subject to a fee.

    Please Arrive on Time for Appointments

    We understand that delays can happen however we try to keep our doctors on time. Arriving late to your appointment cuts into valuable time spent with the doctor and may result in the appointment needing to be rescheduled and may be subject to a fee.

    Payment

    We will gladly prepare a written estimate for services (please ask our doctor or the receptionist). We accept Visa, Mastercard, Discover, and American Express, cash and personal checks (only with verification of valid drivers license or other ID at time of payment).  Returned checks are subject to a $35.00 service fee.

    In addition, we offer a 3rd party financing options for our clients via Care Credit. Our standard CareCredit plan requires a minimum $200 invoice and provides up to 6 months to pay the outstanding balance. CareCredit requires that payment only be made for services as they are rendered, and we cannot charge services to your account in advance. 

    Full payment is due at the time of service. This includes any charges/fees agreed to by your authorized proxy. Client will be responsible for a 1.5% monthly finance charge on accounts over 30 days and any collection and/or legal fees on accounts over 90 days. Your signature below indicates your agreement with these policies.

    Prescriptions

    We have a comprehensive pharmacy on premises and carry many of the products that our veterinarians may prescribe for your pet. However, pursuant to California Business & Professions Code, Sec. 4170, Article 12: Prescriber Dispensing, you may request a written prescription to be filled by a pharmacy of your choice rather than filling medication(s) at our hospital.

    Online Pharmacy

    We offer you the convenience of online ordering and home delivery with our online pharmacy. We provide affordable, quality medications and prescription diets, coupled with convenient Auto Ship programs so your pet’s medications are delivered to your home on time, just when you need them. Our online pharmacy link can be found on our website at Muller Veterinary Hospital

    Medical Record Copies

    Should you need a personal copy of your pet’s medical record, there is a fee for printing or photocopying the records. We will fax/email records to you, referral veterinarians and insurance companies free of charge.

    Insurance

    For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier. Once your claim is submitted, your insurance company will reimburse you for the services they cover under your policy.

    Thank you for entrusting us with the care of your pet(s). If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your pet.

  • Please sign in the section below acknowledging you have read and completed this form as the person responsible for this pet(s), and that you are 18 years or older.

  • Internet Permission: Do we have your permission to post pictures of your pet(s), you and your pet(s) and/or your pet(s) and our team on Facebook, Instagram, Twitter, www.mullerveterinaryhospital.com and any other marketing and/or other social media outlets we may choose to use?*
  • Muller Veterinary Hospital uses email, text and our own hospital app for communications regarding our patient's reminders for health care needs. Do we have your permission to contact you via email, text and/or our app regarding these reminders? *

  • Please press the Submit Form tab.  Thank you and we'll see you soon!

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