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Home
Take a Tour with Us
Our Services
Preventive Care Plans
Contact Us
New Client Form
Refer a Friend
Petly Portal
About us
Our Policies
Online Store
Our Blogs
Pet Talk with Nancy
Guest Blogs
Testimonials
Client Resources
Client Form
How to get your cat to us safe and happy
TeleVet
Giving Back
Privacy Policy
Resources
Care Credit
newpatientregistration_vdogs_v2.pdf
File Size:
63 kb
File Type:
pdf
Download File
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Indicates required field
Your Name
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First
Last
Additional contact person who is authorize to make medical and financial decisions on the care of your pet(s).
Secondary Person
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First
Last
[object Object]
Your Address
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Line 1
Line 2
City
State
Zip Code
Country
**We have a patient portal to communicate all lab results, birthday greetings and newsletters. It is all done via email.
Your Email
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Your Phone Number
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Your Cell Phone Number if different then phone number.
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Employer
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How did you learn about us?
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Save time and Money!
I am interested in substantial savings on the best care for my pet through a CVHC Petly Plan. Please tell me more.
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Yes
Method of Payment Today: For Your convenience, at the time we perform services, we accept MasterCard, Visa, American Express, Care Credit, as well as cash or Check (with valid driver's license.)
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Cash
Check
Debit/Credit Card
Care Credit
If you have more then one pet don't worry, we will get that pet's information when you are here and update the file.
Pet 1 Name:
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Untitled
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Species (cat, dog, etc.)
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Breed
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Age/Birthday:
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Color
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Spayed or Neutered
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Does your pet have any allergies?
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Has your pet ever had a reaction to vaccines or medication?
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Where should be call for previous medical history? Previous vet?
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If it becomes necessary during your pet's visit, do you want us to administer CPR?
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Yes
No
Terms of Service
Payment is full is required at the time of services rendered.
We do not offer any form of billing.
Advanced minimum deposit of half of your pet's medical care plan is expected for all orthopedic surgeries and ultrasounds. This also applies to extensive treatment and severely ill patients.
Treatment Authorization and Information/Photo Release
I am the owner, or the agent of the owner, of the above described pet and have the authority to execute this agreement. I authorize Companion Veterinary Heath Center, LLC to examine and treat the above pet. I have read and agreed to the financial policy of CVHC. I accept full financial responsibility for the pet. I understand that the payment for diagnostic tests and treatment that I authorize by submitting this form or verbally will be due at the my pet is dismissed from the hospital. I also understand that if my pet is hospitalized by CVHC, he/she will need to be picked-up upon the agreed time.
Case information and /or photos may be used in teaching, continuing education, veterinary literature, and social media. I authorize release of case/patient information for such purposes. Patient confidentiality with be maintained. In the event of ownership transfer, I authorize the release of medical information to the new owner of this animal.
By submitting this form you agree to all terms and releases.
Submit