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COMMUNITY VETERINARY CLINIC

New Patient & Client Information Form

Thank you for giving us the opportunity to care for your pet! Help us meet your needs by taking a few moments to fill out this information form. Please provide all information pertinent to you & your best friend!

Sex:
Is your pet spayed/neutered?:
Are your pet's vaccines current?:

If you have any existing medical records for your pet, please upload them here (Max 15MB document size):

UPLOAD FILE
Upload a document (Max 15MB)
If you do not have medical records for your pet, do we have permission to contact your previous vet for your pet’s medical records?:
Preferred methods of communication for reminders (check & fill out all that apply): Required

To help prevent the spread of infectious diseases, ALL hospitalized animals must be current on all vaccines.

Fees & Payment Agreement

 

We will gladly prepare a written estimate for any services if you desire. Please ask a receptionist or doctor. All

professional fees are due at the time services are rendered. I understand every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital care and handling. I hereby authorize this hospital to receive, prescribe for, treat, or perform surgery upon my pet(s).

 

Furthermore, I agree to any fees for services rendered at the time the pet is discharged from the hospital or the service is otherwise terminated. I agree to pay for the reasonable costs of collection in the event that collection efforts become necessary. There will be a service charge for any check returned unpaid. There will also be a monthly statement charge of $5.00 on unpaid balances due.

Success! Form submitted.

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