New Client/Patient Intake Form

New Client/Patient Intake Form

Mother Lode Veterinary Hospital
Primary Owner:
Name

First NameLast Name
Phone Number(s)
Email
example@example.com
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physical Address (If Different From Mailing)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Owner
Name

First NameLast Name
Phone Number(s)
Email
example@example.com
Pet Information
Would you be interested in enrolling any of your pets in our Educational Donor Program? If so, please specify which pets. If not, kindly leave the field blank.
If you would like us to call your previous veterinarian for records please provide practice information below. Please note : All pets must be current on rabies vaccination. Proof is required at your appointment. If records are unavailable, you understand the rabies vaccine will be administered during your visit.
If your pet was recently adopted please provide shelter information.
If a friend referred you to Mother Lode Veterinary Hospital, please enter their first and last name, as it appears on their account, below so they can receive referral points:

First NameLast Name
Does your pet have insurance?
If your pet has insurance, who is the Insurance Provider?
Signature to provide consent to release medical records to listed provider as requested:
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.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Signature
Should be Empty: