Maplewood New Client Form

New Client Information Form
Client Information
Owner Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Place Of Employment
Business Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
E-mail*
example@example.com
Spouse’s Name
Spouse's Phone
Please enter a valid phone number.
Preferred Method of Contact

TextPhone CallEmail
Personal Recommendation - Whom May We Thank? (Name)
Pet Information
Pet #1 Name*
Breed
Color
Species

DogCat
Sex

FemaleSpayed FemaleMaleNeutered Male
Date Of Birth
Do you have another pet to add?

YesNo
Pet #2 Name*
Breed
Color
Species

DogCat
Sex

FemaleSpayed FemaleMaleNeutered Male
Date Of Birth
Do you have another pet to add?

YesNo
Pet #3 Name*
Breed
Color
Species

DogCat
Sex

FemaleSpayed FemaleMaleNeutered Male
Date Of Birth
Please let us know if you, your family members, or your pet are allergic to peanuts.

YesNo
Can we give vaccine information to your groomer, pet daycare, rescue, or boarding facility?

YesNo
Photo Permission
I grant Maplewood Veterinary Center, its representative and employees the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically. I agree that Prairie Lane Veterinary Hospital may use such photographs of me and/or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and web content.*

The above may take photos of me and/or my pet.The above may NOT take photos of me and/or my pet.
Payment Options

You can choose from:
- Cash
- Check
- Visa®
- MasterCard®
- American Express®
- Discover Card®
- Convenient Monthly Payment Plans¹ from Care Credit® (¹Subject to credit approval)
  - Allow you to begin treatment today and pay overtime.
  - Available for any treatment amount
  - Can be used repeatedly - for your entire family - without having to reapply¹
  - See CareCredit.com for more information.
Deposit Policy
New clients are required to pay a $35 deposit at the time of scheduling their first appointment. (Each pet scheduled requires its' own deposit)

The deposit will be applied toward the first appointment's final bill. If the appointment is rescheduled, the deposit will be applied to the rescheduled appointment.

The deposit will be forfeited in the occurrence of a "no show", a cancellation with less than a 24-hour notice or if not applied to an appointment within 30 days of making the initial appointment
Cancellation Policy
We strive to provide the best in patient and client care. As a result, we work hard to protect the time that is set aside for you and your pet. Please review the policies below regarding appointment cancellations as well as if you are late or no-show to an appointment.

Cancellation: If you need to cancel a scheduled appointment, please contact us no later than 24 hours before your appointment time. You can call the clinic at 563-888-5850 or email us at: reception@maplewood.vet. Please be sure to include your information, your pet’s information, and the appointment day and time. If you do not cancel within the 24-hour period, you will incur a late cancellation fee of $35.

No Show: If you no-show for an appointment (you do not notify us you will not make it) you will be charged a no-show fee of $35. If you no-show for an appointment 3 times, you will need to pre-pay the exam fee when scheduling your appointment.

Late Arrival: If you arrive 10 minutes late or more for your scheduled appointment, you may be asked to reschedule your appointment, or given the option to wait until Dr. is available depending on the schedule at that time. If you are running late, please call the clinic at 563-888-5850 to discuss options with one of our client service receptionists.
Financial Policy Acceptance

I understand payment is to be made at the time any services are rendered. Overdue accounts are assessed a 2% per month finance charge with a minimum of $5.00. Accounts submitted for collection are inclusive of outstanding balance, finance charges, attorney fees, and collection fees.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

New Client Information Form

Client Information

Pet Information

Photo Permission

Payment Options

Deposit Policy

Cancellation Policy

Financial Policy Acceptance