New Client Form

New Client Form

Thank you for choosing Castlerock Veterinary Hospital for your pet's needs
Owner Information
Date

First Name   Last Name (Owner)  Area Code   Phone Number

First Name   Last Name   (Spouse/Partner)   Area Code   Phone Number

Street Address   Address Line 2   City   State   Zip

Email
Have you been to Castlerock before?

YesNo
Appointment Date/Time
Previous/Primary Veterinary Clinic
How did you learn about us?

IndividualWebsite/FacebookPrimary VetSign
Our staff uses a scribing application that aides in the note taking process during exams. Do you consent to the using this during your visit? (Please let us know if you would like a copy of the release)

Yes, I consent to them using ScribeNo, I would like to decline
Do you want us to send a copy of the exam performed today to your primary veterinarian?

Yes, I will be continuing care at my primary veterinarianNo, I want to continue care here
Pet Information
Pet NameDOB/Est.Age
Sex Spayed/Neutered Breed
Color
My pet is experiencing the following symptoms (write all that apply):
Does your pet have any specific medical conditions and/or is your pet on any medications we should be aware of?

YesNo
If your pet is on medication, please explain (give the dose and how often the are getting it)
In the event of life-threatening medical, surgical or anesthetic crisis:

I wish to have CPR to be performed, and I understand I would be contacted immediately by staff. I understand additional costs would occur.I do not want you to resuscitate my pet.
Hospital Financial Policy
PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED. An estimate will be provided after the initial assessment of your pet. In the event of hospitalization, a deposit of 100% of the lower end of the estimate will be due at the time of admission. Payment, in full, is due at the time of discharge. We understand that visiting us on an urgent basis can be stressful, and that treatment costs may be more than anticipated due to the nature of your pet's medical problem. Often, friends and family may be able to help in a crisis. If you have any financial concerns or questions about our policies, please see one of our knowledgeable staff. Please see alternative sources of funding below:

CashCredit/DebitCare Credit (we may need proof of available funds before services are given)Scratch Pay
By signing the line below, I am stating that I am the owner of this pet. If i am an "acting agent" (not the owner) I have made the staff aware, and arrangments have already been made between Castlerock and the pet's owner stating I am authorized to approve treatments.
Permission to Treat:

I authorize the doctors to perform treatment for my pet. Payment in full is due at the time of service. I assume responsibility for all charges incurred in the care of this animal. If my pet requires admission to the hospital, I understand emergency veterinary care is not intended to be a subsitute for complete veteriary care.
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New Client Form

Owner Information

Pet Information

Hospital Financial Policy