New Client and Pet Information Form

New Client and Pet Information Form
Thank you for trusting Hillcrest Veterinary Clinic for your pet's care! Please fill out the form below and attach your pet's previous medical records. Once we receive this information, we'll give you a call to schedule your first visit with us.

**We are currently scheduling out about 6-8 weeks for our new client appointments.**
We do require a deposit for all new client appointments here at Hillcrest Veterinary Clinic. The deposit is $62.00 and is due at the time of scheduling. It covers the cost of the physical exam and will be applied to your invoice at your appointment.

If you need to cancel or reschedule, we can refund or transfer your deposit. It will only be forfeit if you no-show for your appointment*.

If your deposit is forfeit due to a no-show and you wish to reschedule, a new deposit will need to be taken prior to rescheduling.

*"No-show" is defined as missing your appointment with no advance notice given to the Clinic. 48 hours advanced notice is required to cancel or reschedule with no penalty.
Owner Information
All fields marked with * are required and must be filled.
If not applicable, enter N/A.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Spouse/Co-Owner Name

First NameLast Name
Spouse/Co-Owner Phone Number
Please enter a valid phone number.
Spouse/Co-Owner Email
example@example.com
Pet Information
Pet's Name*
Pet Species*
Pet Breed*
Ex: German Shepherd, Husky, DSH (short-haired cat), DLH (long-haired cat), Persian, etc.
Pet Sex/Altered Status*
Pet Color/Markings*
Ex: Black/White, Brindle, Tri-Color, Merle, Tabby, Tuxedo, etc.
Pet Date of Birth*

MonthDayYear
Is the date of birth estimated or known?*

EstimatedKnown
Is your pet microchipped?*

YesNoUnsure
If yes, please enter the number:
15 Digit ISO Compliant Microchip Number
Does your pet have any allergies (medications, vaccines, foods)?*

YesNoUnsure
If yes, please list them here:
Ex: Chicken, NSAIDs, Vaccine Reactions, etc
Does your pet have any behavioral triggers or physical limitations we should be aware of?*

YesNoUnsure
If Yes, Please List Them Here:
Ex: Dog/Leash Reactive, Fearful, Back Pain/Injury, Blind/Deaf, Megaesophagus, etc
Is your pet currently on flea, tick, and/or heartworm and intestinal parasite prevention?*

NexgardNexgard PLUSHeartgard PLUSSimparica TRIOInterceptor PLUSBravectoRevolution PLUSAdvantage IIAdvantix IIAdvantage MultiSeresto CollarFrontlineOther (please type below)None
Other:
Is your pet currently on any other medications or supplements?*

Cosequin, Dasuquin, Glycoflex, or another joint supplementPsyllium husk powder, Metamucil, or another fiber supplementForti-Flora, Mycequin, or another probioticNoneOther (please type below)
Other:
We must have your pet's previous medical history in order to schedule an appointment. If you have a kitten or puppy with no previous medical history, please email us at reception@hillcrestveterinaryclinic.com for a different intake form.
Please upload your pet's records here:*

Cancelof
Medical Record Release Authorization

In the event that another veterinary clinic, groomer, boarding facility, or adoption organization contacts Hillcrest Veterinary Clinic regarding your pet(s) or their medical records, we ask that our clients provide us with the authorization to release those records so we can better protect your privacy and personal information. Please choose the records you would be comfortable with Hillcrest Veterinary Clinic sharing with other professional organizations. You can decline to authorize any record release, in which case we will contact you directly if there is an inquiry or request for records. You may also revoke this authorization at any time by emailing us at reception@hillcrestveterinaryclinic.com and providing your name, your pet's name, and your request for revocation.
Please click the square next to each record you wish to authorize.
I, the client, authorize and request the disclosure of all protected information I select below:*

All medical records including in house and send out lab work results, radiographs, previous/other veterinary hospital records, emergency veterinary records, referral records and diagnostics, and client/clinic communication.All laboratory, histology, cytology, pathology, vaccine titer records and specimens; radiology records and films including videos/CDs/films/reels and reports.All pharmacy/prescription records including NDC numbers and drug information handouts/monographs.All billing records including all statements, insurance claim forms, itemized bills, and records of billing to third party payers and payment or denial of benefitsVaccines only for boarding, grooming, or daycare purposes.Confirmation of active veterinary care, including whether or not each pet is spayed/neutered, up to date on vaccines, current on flea medication, and microchipped.I do not authorize Hillcrest Veterinary Clinic to release any information regarding my pet(s) or my account without first contacting me directly.Other (enter here)
Please click the square next to each line to indicate you've read and understand our authorization policies.
I, the client, agree with the following statements:*

I understand I have a right to revoke this authorization in writing at any time, except to the extent information has already been released in reliance upon this authorization.I understand the information released in response to this authorization may be re-disclosed to other parties.I understand my pet's treatment or payment for my pet's treatment cannot be conditioned on the signing of this authorization.I understand any facsimile, copy, or photocopy of this authorization shall authorize me to release the records requested herein.I understand this authorization shall be in force and effect for the life of my pet unless revoked in writing.
Acknowledgement and Signature
Please note: We take pride in the quality of service and medical care you trust us with providing you and your pet. In an effort to maintain these standards, and to keep your costs down, we do not bill for services rendered. Payment is due at the time of service.

We accept cash, check, Care Credit, VISA, MasterCard, Discover, and American Express.

By signing this form, you acknowledge that the information provided is accurate to the best of your knowledge, and that you agree to pay for professional services and medications as they are rendered. You may ask us for a copy of our financial policy or for an estimate of expected services at any time.

Please arrive to your appointment at your scheduled time. Due to our current scheduling restrictions, if you are more than 10 minutes late we will need to reschedule your appointment.

Failure to reschedule or cancel your appointment at least 48 hours before your scheduled appointment time will result in the forfeiture of your deposit, and a new deposit will be required before you can schedule a new appointment.
I hereby certify that the information on this form is true and accurate. I acknowledge the payment and scheduling policies set forth in the above paragraphs.*

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Today's Date*

MonthDayYear
Should be Empty:

New Client and Pet Information Form

Owner Information

Pet Information

Medical Record Release Authorization

Acknowledgement and Signature