New Client Information
This form is designed to quickly gather the needed information and get you added to our scheduling system! If you are already an established client, you do not need to fill this form out again; you may call or text 256-614-5444 with your requests.
**You will be contacted directly for appointment confirmation! Please allow us time to get back with you with available appointment times!**
Note: Under most circumstances, we are unable to offer same day appointments for new clients, due to the overwhelming level of interest in our services. We will do our best to accommodate all requests on a first-come, first-served basis, however our location for each day is typically set 7-10 days in advanced.
Client (Pet Owner) Name
First Name
Last Name
Spouse/Other Owner, if applicable
First Name
Last Name
Primary Cell Phone Number
*
Please enter a valid phone number. You will be contacted on this number regarding your pet's care.
Format: (000) 000-0000.
Email
*
example@example.com
Address for Appointment
*
Street Address of where Elk River Vet will arrive for your pet's care. If this address is different than your home address, please note that in the "NOTES" section, below!
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
NOTES: Please list any directions to your location if your residence can be difficult to find, or any other pertinent information about your location ("Park at Driveway entrance", gate code information, etc)
Primary Pet Name (Required for Apt Scheduling)
*
Pet Name
Pet Species, Breed, Age, Gender
Additional Pet(s) Name
Pet Name
Pet Species, Breed, Age, Gender
Additional Pet(s) Name
Pet Name
Pet Species, Breed, Age, Gender
What service(s) are you needing? If you are having an emergency and/or it is outside of our business hours, PLEASE CALL MADISON VET ER AT 256-434-5290 OR FLORENCE ANIMAL ER AT 256-740-4800 AS SOON AS POSSIBLE. You may also list any additional pets here and describe what services they need.
*
Please Confirm your understanding of the following:
I understand that this is only a new client appointment request and that if I haven't heard back from ERVS within 48 hours (or 72 hours on weekends), I should contact ERVS directly at (256) 614-5444.
I understand that there is a $25 cancellation fee per pet scheduled if an appointment is cancelled within 24 hours of their appointment. A $50 fee per pet scheduled will occur on all same-day cancellations or "no show/unconfirmed" appointments. This fee will have to be paid in full before I am allowed to reschedule.
I understand that charging for services/product on my account is not allowed. I understand payment is due in full at the time of the visit unless previously arranged directly with ERVS. ERVS understands you may not always be able to be available in person for your pet's appointment, so we are able to accept payment via card remotely. We accept cash, card or check (with DL number) in person. We do not accept care credit at this time. Any balance left unpaid after 15 days is subject to a 2% finance charge, and will accrue additional finance charges every 15 days. If your account is sent to collections, you will be responsible for the outstanding balance, collections charges and all attorney and court fees associated with collection on the account.
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