Dwight New Patient Form

New Patient Form
Owner/Client Name*

First NameLast Name
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Email*
example@example.com
Driver's License
Employer
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Spouse/Co-Owner Name

First NameLast Name
Spouse/Co-Owner Phone
Please enter a valid phone number.Format: (000) 000-0000.
Additional Information
RadioSignNewspaperInternetYellow PagesYelpFacebookEmployeeOther Hospital/DoctorFriendOther
Which employee?*
Which hospital/doctor?*
What if your friend's name?*
CashCheckDebitCredit Card (Am.Express, Discover, Mastercard, Visa)CareCredit
Pet Information
NOTE: Please send a copy of your pet's records to info@dwightvet.com at least 48 hours prior to appointment.
Pet #1 Name*
DogCatOther
Date of Birth (Or Approximate Age)*
Breed*
Color*
MaleFemale
YesNo
YesNo
If yes, what is the number #?
YesNo
Dog #1 - Has your pet been tested or vaccinated for:
YesNo
Date of Rabies Vaccine
YesNo
Date of Distemper (DA2PP) Vaccine
YesNo
Date of Heartworm Test
YesNo
Date of Internal Parasites Test
Other
Vaccinated Where?
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Any significant medical history or known allergies?
Any medications your pet is currently on?
Cat #1 - Has your pet been tested or vaccinated for:
YesNo
Date of Rabies Vaccine
YesNo
Date of Distemper (FVRCP) Vaccine
YesNo
Date of Leukemia Vaccine
YesNo
Date of Internal Parasites Test
Other
Vaccinated Where?
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Any significant medical history or known allergies?
Any medications your pet is currently on?
Additional Pet Information
YesNo
Pet #2 Name
DogCatOther
Date of Birth (Or Approximate Age)
Breed
Color
MaleFemale
YesNo
YesNo
If yes, what is the number #?
YesNo
Dog #2 - Has your pet been tested or vaccinated for:
YesNo
Date of Rabies Vaccine
YesNo
Date of Distemper (DA2PP) Vaccine
YesNo
Date of Heartworm Test
YesNo
Date of Internal Parasites Test
Other
Vaccinated Where?
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Any significant medical history or known allergies?
Any medications your pet is currently on?
Cat #2 - Has your pet been tested or vaccinated for:
YesNo
Date of Rabies Vaccine
YesNo
Date of Distemper (FVRCP) Vaccine
YesNo
Date of Leukemia Vaccine
YesNo
Date of Internal Parasites Test
Other
Vaccinated Where?
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Any significant medical history or known allergies?
Any medications your pet is currently on?
Client Signature, Testimonial and Photo Release Form
New Client Policy

I understand and acknowledge that Dwight Veterinary Clinic requires a $50 non-refundable deposit to secure an appointment for new clients. Failure to give at least 24-hours cancellation notice to the practice will result in the forfeiture of the deposit.
Signature*
No Show, Late and Cancellation Policy

I understand and acknowledge that it is the policy of the practice to monitor and manage appointment no-shows and late cancellations. Dwight Veterinary Clinic's goal is to provide excellent care to each patient in a timely manner. If it is necessary to cancel an appointment, clients are required to call, text or email at least 24 hours before their appointment time. Notification allows the practice to better utilize appointments for other patients in need of prompt medical care.

Appointments must be cancelled at least 24 hours prior to the scheduled appointment time. In the event a patient is a "no-show" for an appointment, Dwight Veterinary Clinic reserves the right to request a $50 deposit to secure any future appointments. In the event a patient is a "late arrival" to their appointment (more than 7 minutes from their scheduled time) and cannot be seen by the provider on the same day, they will be rescheduled for a future clinic visit, if available. In the event of three (3) documented late arrivals or same day cancellations, Dwight Veterinary Clinic reserves the right to request a $50 deposit to secure any future appointments.
Signature*
Treatment Authorization Policy

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet(s). I assume responsibility for all charges accrued in the care of this animal presented by me or my agents. I also understand that the charges will be paid in full at the time of services rendered or at release and that a deposit may be required for surgical treatment or hospitalization. I understand that I am responsible for a returned check fee of "25. I agree to pay for the reasonable costs of collection, attorney fees, and court costs in the event that collection efforts become necessary. I HAVE READ AND UNDERSTAND THE ABOVE "Treatment Authorization Policy".

RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENT/GUARDIAN AS EVIDENCED BY THEIR SIGNATURE BELOW. I ACCEPT:
Print Name*
Signature*
Date*

MonthDayYear
Date
If under 18, PARENT/GUARDIAN MUST SIGN:
Date

MonthDayYear
Date
ScribbleVet Consent and Release
Our veterinary services utilize ScribbleVet, a tool from Kairo Care, Inc., which records your pet's appointments for improved clinical documentation. We need your consent to proceed with the recording.

By signing this agreement:
1. Appointment Recording: You agree that your vet appointments may be recorded. If you don't want to be recorded, let us know.
2. Usage Rights: You grant us permission to share these recordings, and any other materials you choose to provide, for the purpose of improved clinical documentation.
3. Age Confirmation & Understanding: You affirm that you are at least eighteen years old, and that you understand and accept the terms in this agreement.

We are committed to providing the best care for your pet in a manner comfortable for both of you.
Client's Name*

First NameLast Name
Client's Signature*
Date*

MonthDayYear
Date
Digital Media Release

I hereby grant the Dwight Veterinary Clinic permission to use my testimonial or likeness in a photograph, video, or other digital media ("Photo") in any and all of its publications, including web-based publications, without payment or other consideration, for purposes of advertising the hospital staff or services. I understand and agree that all Photos will become the property of the Dwight Veterinary Clinic and will not be returned. I hereby irrevocably authorize the Dwight Veterinary Clinic to edit, alter, copy, exhibit, publish, or distribute any testimonial and Photo for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my testimonial or likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the testimonial or Photo. I hereby hold harmless, release, and forever discharge the Dwight Veterinary Clinic from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENT/GUARDIAN AS EVIDENCED BY THEIR SIGNATURE BELOW. I ACCEPT:
Print Name
Signature
Date

MonthDayYear
Date
If under 18, PARENT/GUARDIAN MUST SIGN:
Date

MonthDayYear
Date
Should be Empty:

New Patient Form

Additional Information

Pet Information

Dog #1 - Has your pet been tested or vaccinated for:

Cat #1 - Has your pet been tested or vaccinated for:

Additional Pet Information

Dog #2 - Has your pet been tested or vaccinated for:

Cat #2 - Has your pet been tested or vaccinated for:

Client Signature, Testimonial and Photo Release Form

ScribbleVet Consent and Release