• New Client/Patient Intake Form

    New Client/Patient Intake Form

    Mother Lode Veterinary Hospital
  • Primary Owner:

  • Secondary Owner

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  • I, the undersigned, hereby acknowledge and agree to the following terms and conditions regarding the care of my pet at Mother Lode Veterinary Hospital:

    • I confirm that I am the true and legal owner of the pet(s) listed above. 
    • I verify that I am 18 years of age or older.
    • I understand that payment for all services rendered at Mother Lode Veterinary Hospital is due in full at the time of service.
    • I understand that there are no guarantees as to the results of any procedures, diagnostics, vaccinations, or treatments provided to my pet.
    • I authorize the staff to walk my canine pet(s) outside the hospital as needed for exercise, bathroom breaks, or other purposes.
    • I consent to my pet being scanned for a microchip, and if one is found, I understand that it is Mother Lode Veterinary Hospital policy to contact the registered microchip owner. 
    • I agree that I, or any authorized agent representing me, will always treat the staff at Mother Lode Veterinary Hospital with respect. This includes communication through any form of correspondence. I acknowledge that the hospital has a zero-tolerance policy for swearing, yelling, threatening, or any form of disrespectful speech or behavior, whether in person or via digital platforms. I understand that Mother Lode Veterinary Hospital reserves the right to terminate services at any time if this zero-tolerance policy is violated.
    • At Mother Lode Veterinary Hospital, we value direct communication and kindly ask that any service or care concerns be discussed with our practice owners or practice manager before leaving public online feedback. Leaving a negative review without prior internal resolution will lead to termination of services, as it negatively impacts the trust and relationship we strive to maintain with our clients and staff.

    By signing below, I acknowledge that I have read, understood, and agree to the terms outlined in this consent form.

     

     

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