New Client Information Sheet

Client Name*

First NameLast Name

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please check the best number to reach you at*

Home PhoneWork PhoneCell Phone

Home Phone

Work Phone

Cell Phone

Spouses Name

First NameLast Name

Spouse Cell Phone

Email Address

example@example.com

Are you an active service member or veteran?

YesNo

How did you hear about us?

(If referred by a friend, put their name above so we can give them a referral credit)

(If Other, Please Specify)

Name

Breed

Color

Age

DOB

Gender (Please select one)

MaleFemaleNeutered MaleSpayed Female

We use an automated service called Rapport that will email/text you your pet’s veterinary reminders and will also send confirmations of appointments you make. MyPetsWellness is available in the App Store for iOS devices, or online for Android devices. You will be able to see each pet's upcoming appointments, vaccine reminders, and prescriptions. You can even book an appointment, or refill a prescription. In addition, you can upload your favorite pet photos.

Financial Policy

We strongly feel that our clients and patients deserve the very best veterinary care we can provide. We do as much as we can to try and hold down the cost of veterinary care. Further, we feel that everyone benefits when definitive financial arrangements are agreed upon. The following is a summary of our payment policy.

ALL PAYMENT IS EXPECTED AT THE TIME OF SERVICE

360° PET MEDICAL accepts cash, personal checks, VISA, MasterCard, Discover, American Express and Care Credit (a 3rd party provider that offers monthly, NO INTEREST payment plans)

RETURNED CHECKS
360° PET MEDICAL charges $25 for returned or NSF checks.

FINANCE CHARGES
Unpaid balances will accrue monthly finance charges of 1.5%.

DEPOSITS
360° PET MEDICAL requires a deposit prior to making an appointment for all new clients. This deposit goes 100% to your booked appointment and is only forfeit if it is late-canceled (less thank 24 hours) or the client no-shows. Deposit required depends on service requested.

ESTIMATES
360° PET MEDICAL presents treatments plans with estimated fees for all procedures and reviews them with its clients. Treatment plans must be signed by the client and a deposit may be collected equal to 50% of the high side of the estimate fee.

INSURANCE
360° PET MEDICAL is happy to assist clients with filing their pet insurance claims. Please note that services are rendered to you, not to your insurance company. An insurance company rarely covers the entire cost of services. Therefore, services must be paid for in full prior to filing insurance claims.

MISSED APPOINTMENTS/LATE CANCELLATIONS
Broken appointments represent a cost to us, to you and to other clients who could have been seen in the time set aside for you. We require a minimum 24 hours-notice to cancel any appointment. Clients with more than 2 instances of late-cancelations or no-shows will be required to pay an appointment deposit going forward. Excessive abuse of scheduled appointments may result in discharge from the practice.

I have read and understand the 360° PET MEDICAL Financial Policy. I agree that if it becomes necessary to forward my account to a collection agency, in addition to the amount owed, I also will be responsible for the fee charged by the collection agency for costs of collection.

Signature*

Client Information

Patient Information

Financial Policy