New-Client-New-Patient-Forms

New Client/New Patient Form

Pumpkin Hill Veterinary Clinic - Byron, NY 14422 - 585-548-9097 - pumpkinhillvet@gmail.com
To ensure the best care for pets, and quality communication with owners, please provide the following: Are you a returning client?

YESNO
Owner's Name (Owner must be 18 or older)
Pumpkin Hill Veterinary Clinic is granted permission to use and/or publish my or my pet's photograph or image (including audio, film, digital image, or other media) for educational purposes on their respective websites or for the promotion of their supported products. I understand that I and my pets are not being compensated in any way for the use of our images and that I/we do not have approval over the final product in which it appears. I hereby release Pumpkin Hill Veterinary Clinic and all persons acting under their permission or authority from any and all claims of liability arising out of the use of our images. This release shall bind our heirs, guardians, assigns, and legal representatives.
Address: (Street, City, State, Zip)
Home Phone Number:
Mobile Phone Number:
Do you accept text messages?

YESNO
Subscriber uses PetDesk° R to manage client communications, vaccination reminders, appointment confirmations health alerts, product recalls, clinic alerts and product recommendations. You agree that we may share your name, pet's name, email address, address, and phone number with only PetDesk to facilitate this process. To learn more about PetDesk or their privacy policies please visit www.PetDesk.com or download their iOS or Android mobile applications.
Email address:
Spouse/Significant Other Name:
Spouse/Significant Other Phone:
Spouse/Significant Other Email:
Do they accept texts?

YESNO
Is anyone else authorized to drop off, pickup or make medical decisions, including euthanasia for your pet(s)? If so, include their name and phone number:
Patient Name:
Patient Species:
Breed:
Patient Sex:
Spayed or Neutered?
Patient Age:
Patient Birthdate:
Vaccine Dates: (Please provide paperwork for our records)
Dog, Rabies:
Dog, Distemper/Parvo:
Dog, Heartworm Test:
Cat, Rabies:
Cat, Distemper:
Cat, Leukemia:
Known Allergies?
Special Diet or medications?
Appointment Scheduled Date and Time:
Appointment, Reason for Visit:
Have you taken your pet(s) to a veterinarian before?

YESNO
Previous Veterinarian?
Any reason for switching veterinarians?
How did you hear about us? Were you referred?
Would you consider seeing us for routine visits?

YESNO
** In Signing below, I agree that the above information is true and accurate:**
Signature

Clear
Printed Name

First NameLast Name
Date

MonthDayYear
Date
Financial Agreement
Owner Name

First NameLast Name
All fees are due upon rendering of services. Please indicate your choice of payment method:

CashCheck (Must have Valid ID)Master CardDiscoverVisaAmerican ExpressCare CreditInsurance
In bringing my pets to Pumpkin Hill Veterinary Clinic I understand the following:
- I understand that with my signed consent I effectively authorize at the time of visit(s) all treatments `performed by licensed staff.
- I assume financial responsibility for all charges incurred and agree to pay all such charges at the time medical care services are rendered or as arranged prior to the examination and/or treatment of my animal(s).
- I understand that a $300-$350 deposit is required at the time of admittance for hospitalized animals. ⎯ I understand that there may be an additional $25.00 fee for “walk-in service,” without a prior scheduled appointment.
- I understand that the use of retractable leashes is prohibited as a form of pet restraint at PHVC and could result in serious legal liabilities for a pet owner.
- I understand that any balance over 14 days will be sent to a collection agency and further services will be prohibited.
- I understand that there will be an additional charge of $35.00 for all returned checks.
** In signing below, I certify that I have read, understand and comply to agree with the above conditions. I also agree that the information I have provided above is accurate:**
Signature

Clear
Date

MonthDayYear
Date
Printed Name of Owner or Responsible Party:

First NameLast Name
Media Release and PetDesk Statement
Pumpkin Hill Veterinary Clinic is granted permission to use and/or publish my or my pet’s photograph or image (including audio, film, digital image, or other media) for educational purposes on their respective websites or for the promotion of their supported products. I understand that I and my pets are not being compensated in any way for the use of our images and that I/we do not have approval over the final product in which it appears. I hereby release Pumpkin Hill Veterinary Clinic and all persons acting under their permission or authority from any and all claims of liability arising out of the use of our images. This release shall bind our heirs, guardians, assigns, and legal representatives.
Signature

Clear
Date

MonthDayYear
Date
Printed Name of Owner or Responsible Party

First NameLast Name
Please Sign here if you decline

Clear
PetDesk® Release Statement Subscriber uses PetDesk® to manage client communications, vaccination reminders, appointment confirmations health alerts, product recalls, clinic alerts and product recommendations. You agree that we may share your name, pet’s name, email address, address, and phone number with only PetDesk to facilitate this process. To learn more about PetDesk or their privacy policies please visit www.PetDesk.com or download their iOS or Android mobile applications
Signature

Clear
Date

MonthDayYear
Date
Printed Name of Owner or Responsible Party

First NameLast Name
Please Sign here if you decline:

Clear
Should be Empty:

New Client/New Patient Form

Financial Agreement

Media Release and PetDesk Statement