Virtual Veterinary Behavior Medicine: Client Form

New Client Form

The staff of Virtual Veterinary Behavior Medicine is excited to work with you and your pet!
CLIENT INFORMATION
Name*

First NameLast Name
Address*

Street Address

CityState / Province

Postal / Zip Code
Cell Phone*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Spouse/Other Name
Spouse/Other Phone
Please enter a valid phone number.
Are you 18 years of age or older?*

YesNo
How did you hear about us?*
Email*
example@example.com
Primary Care Veterinarian*
Primary Care Veterinarian Phone Number*
Please enter a valid phone number.
Primary Care Veterinarian Email address*
example@example.com
Do you have pet insurance?*

YesNo
If yes, what provider?
PET INFORMATION

Please fill out the following chart:*

PAYMENT POLICY, PERMISSIONS & RELEASE OF LIABILITY
Payment is due in full at the time of services rendered.

We accept all major credit cards and Care Credit. A $30 service charge will be applied to any returned payment.
I hereby grant Virtual Veterinary Behavior Medicine, its representatives and employees, permission to share my pet’s full medical records with any and all animal medical facilities.*
Please initial that you have read and understand the above paragraph. If you wish to decline, please indicate "DECLINE"
By signing below, I am authorizing the veterinarians and staff of Virtual Veterinary Behavior Medicine to discuss behavioral concerns and discuss these findings and recommendations with your primary care veterinarian for the above described pet. I understand that the primary care veterinarian maintains the veterinarian-client-patient relationship (VCPR) rather than the behavior clincian and understand that the behavior clinicans are working in consultation with the primary care to implement a treatment plan. I am 18 years of age or older. I assume responsibility for all charges incurred in the care of the described pets. I also understand that ALL PROFESSIONAL FEES ARE DUE AT THE TIME OF SCHEDULING.
Signature*

Clear
Date*

MonthDayYear
Date
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New Client Form