BVC New Client Form 2023

WELCOME!!!

Thank you for giving us the opportunity to care for your pet. Please help us meet your needs better by taking a moment to share some important information we will need as we support your pet’s needs today and in the future.
Owner/Primary Contact Information:
Title:

Mr.Mrs.Ms.Other
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Please enter a valid phone number.
What type of phone is this?*

HomeCell
Secondary Phone Number
Please enter a valid phone number.
What type of phone is this?

HomeCell
Email*
example@example.com
What is your preferred method of contact?*

Phone CallTextEmail
In order to prescribe certain medications, we are required to have a form of government issued identification on file. Without this information, we will not provide services for you or your pet.
What type of ID do you have?*

State Drivers LicenseOther
Driver's License State:
Driver's License Expiration

MonthDayYear
Date
Type of government issued ID:
Identification number:
Government Issued ID Type
Upload a photo of your Government issues ID*

Cancelof
Date of Birth*

MonthDayYear
Date
I certify that I am over 18 years of age and am the legal owner of the animal(s) listed below or have the authority to make medical decisions on behalf of the legal owner.*

Yes
Spouse/Significant Other Contact Information:
Title:

Mr.Mrs.Ms.Other
Spouse/Significant Other

First NameLast Name
Spouse/Significant Other Phone Number
Please enter a valid phone number.
What type of phone is this?

HomeCell
Are any other persons over the age of 18 authorized to make medical decisions for your pet(s):

YesNo
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Tell us about your pet(s):
Pet Name:*
Species:*
Age/Birthday*
Gender*
Is this pet spayed or neutered?*
Breed*
Color*
Upload a photo of your pet to be used on their medical chart.

Cancelof
Do you wish to add another pet?

YesNo
Pet Name:*
Species:*
Age/Birthday*
Gender*
Is this pet spayed or neutered?*
Breed*
Color*
Upload a photo of your pet to be used on their medical chart.

Cancelof
Do you wish to add another pet?

YesNo
Pet Name:*
Species:*
Age/Birthday*
Gender*
Is this pet spayed or neutered?*
Breed*
Color*
Upload a photo of your pet to be used on their medical chart.

Cancelof
Do you wish to add another pet?

YesNo
Pet Name:*
Species:*
Age/Birthday*
Gender*
Is this pet spayed or neutered?*
Breed*
Color*
Upload a photo of your pet to be used on their medical chart.

Cancelof
What veterinary clinic can we call for your pets' previous records?
Previous veterinary clinic phone number:
Please enter a valid phone number.
Would you like us to share your pet’s medical records with the above clinic?

YesNo
Do you have pet insurance?

YesNo
Who is your pet insurance provider?
How did you hear about us?*
Who may we thank for referring you?
Brandt Veterinary Clinic Policies

Please initial to signify your acknowledgement of each Brandt Veterinary Clinic policy. Please let us know if you have any questions about any of our policies.
Veterinarian/Client/Patient Relationship
Florida Statute. §474.202 states the requirement of an established Veterinarian/Client/Patient Relationship in order to prescribe, order, or dispense medications for a patient. The VCPR is defined as a veterinarian’s record of a client’s animal which documents that the veterinarian has seen the animal in a professional capacity within a period of 12 months or less. Brandt Veterinary Clinic adheres to this statute and requires annual examinations in order to prescribe and dispense prescription medications and diets. Additionally, medical advice cannot be given without a physical examination by a Brandt Veterinary Clinic veterinarian. The VCPR is also based on mutual trust, respect, and courtesy between the client and Brandt Veterinary Clinic.
Initial*
Audio/Video Surveillance
Brandt Veterinary Clinic uses audio and video surveillance monitoring in public areas of the clinic, including but not limited to, the lobby, exam rooms, treatment areas and parking lot.
Initial*
Online Pharmacies
At Brandt Veterinary Clinic, we understand that cost may play a role in your pet’s care and that the large corporations like discount pharmacies can purchase products in bulk at a lower cost to offer lower prices to consumers. As a small business, while we are not always able to meet the same low costs, we work diligently with manufacturers to provide coupons, rebates, and specials to our clients whenever we are able to. Additionally, veterinary products purchased through veterinary clinics and legitimate veterinary pharmacies/retailers are eligible for manufacturer guarantees and manufacturer rebates that discount online pharmacies cannot offer. For our client’s convenience, we have researched legitimate Veterinary-Verified Internet Pharmacy Practice Sites (VIPPS) approved veterinarian pharmacies and have partnered with VetSource to provide Home Delivery of your pet’s prescription medications and foods. If you would like to purchase your pet’s prescription needs from a source other than Brandt Veterinary Clinic or VetSource, a written prescription can be provided to you at your request so that you may use it at the pharmacy of your choice. Brandt Veterinary Clinic does not work directly with discount online pharmacies as we cannot verify or vouch for the quality or validity of the products that they offer.
Initial*
Medications and Heartworm Prevention
Brandt Veterinary Clinic requires 2 business days for all medication refills. Heartworm preventatives as well as other long-term medications require annual or semi-annual blood work and other health monitoring in order to be dispensed. I acknowledge that for certain medication refills, my pet will need to be up to date on the required monitoring and exams in order for Brandt Veterinary Clinic to dispense or authorize prescriptions.
Initial*
Vaccines and Parasites
Florida Statute. §828.30 requires that dogs, cats and ferrets, 4 months of age or older, be vaccinated against rabies. For the health and safety of our staff, as well as the legal requirement, Brandt Veterinary Clinic requires that all patients have up to date rabies vaccinations in order to receive treatment at our clinic. Pets being seen in the clinic must also be free from external parasites such as fleas and ticks. To prevent the spread of infectious diseases, all hospitalized pets must be current on all required vaccines and free from both internal and external parasites. Patients that come into the clinic with parasites will receive the appropriate parasite treatment at the client’s cost. Your initial authorizes this level of preventive care.
Initial*
Late/Cancellation Policy
We know that our clients have busy schedules, and we respect your time and do our best to have patients seen in a timely manner. In order to see our scheduled appointments in a timely fashion, please let us know as soon as possible if you are running late for your appointment. Arrivals more than 10 minutes late for their scheduled appointment time will be rescheduled. Appointments cancelled less than 24 hours’ before the appointed time are subject to a cancellation fee.
Initial*
Reservation Policy
New clients: A reservation fee for your pet's first appointment is required at the time of scheduling. If you are bringing more than one pet for an exam, a reservation fee will be required for each pet scheduled for your first visit at Brandt Veterinary Clinic. This reservation fee will be applied to the balance of kept appointments.
Appointments cancelled or rescheduled with less than 24 hours’ notice will result in the forfeiture of your reservation fee.

Surgeries: A reservation fee is required at the time of scheduling all anesthetic procedures. This reservation fee will be applied to the balance of kept appointments. Surgeries cancelled or rescheduled with less than 48 hours’ notice will result in the forfeiture of your reservation fee.
Initial*
Media Release
Periodically, photo or audio/video recordings may be taken by Brandt Veterinary Clinic staff members for social media, staff training, marketing or other purposes. I acknowledge that the pictures or recordings taken become the sole and exclusive property of Brandt Veterinary Clinic.
I permit the use of my and my pet’s image and likeness and release Brandt Veterinary Clinic from any and all claims that might arise from the use of these images and recordings.DeclineI permit the use of my pet’s image only and release Brandt Veterinary Clinic from any and all claims that might arise from the use of these images and recordings.Decline
Payment
Payment is due in full at the time services are rendered. We will gladly prepare a written treatment plan withthe estimated cost of your visit if you desire. Please ask us. We accept cash, MasterCard, Visa, Discover, CareCredit and debit cards. After your first visit with us, we can accept checks with identification and a completedCheck Writing Authorization Form. There will be a $30 service charge for any check returned unpaid.For your convenience, Brandt Veterinary Clinic offers safe and secure storage of credit card information toexpedite the check out time for your pet’s care and product needs, in-clinic. Once stored in our computer, our staffdoes not have access to your full credit card number. If you would like to keep your credit card on file with us,please let a staff member know.
Initial*
Your signature below certifies that you are over 18 years of age and are the legal owner of the animal(s) listed above or have the authority to make medical decisions on behalf of the legal owner and acknowledges that you have read and understand Brandt Veterinary Clinic’s policies.
Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

WELCOME!!!

Owner/Primary Contact Information:

In order to prescribe certain medications, we are required to have a form of government issued identification on file. Without this information, we will not provide services for you or your pet.

Spouse/Significant Other Contact Information:

Tell us about your pet(s):

Brandt Veterinary Clinic Policies

Your signature below certifies that you are over 18 years of age and are the legal owner of the animal(s) listed above or have the authority to make medical decisions on behalf of the legal owner and acknowledges that you have read and understand Brandt Veterinary Clinic’s policies.