New Client Form

newpatientregistration_vdogs_v2.pdf
File Size:	63 kb
File Type:	pdf

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* Indicates required field

Your Name *

First

Last

Additional contact person who is authorize to make medical and financial decisions on the care of your pet(s).

Secondary Person *

First

Last

Your Address *

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 *

Your Phone Number *

Your Cell Phone Number if different then phone number. *

Employer *

How did you learn about us? *

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. *

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.) *

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: *

Untitled *

Species (cat, dog, etc.) *

Breed *

Age/Birthday: *

Color *

Spayed or Neutered *

Does your pet have any allergies? *

Has your pet ever had a reaction to vaccines or medication? *

Where should be call for previous medical history? Previous vet? *

If it becomes necessary during your pet's visit, do you want us to administer CPR? *

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.

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