New Client Form

Co-Owner Name (first & last):

Co-Owner Phone Number:

How would you like to be reminded of appointments?*

Phone #

Email

What is the best time to call about your pet?*

How did you hear about us?*

Internet Search

Drive By

Client Referral

Other

If you were referred by a client, what is their name?

Do you want a treatment plan with estimate for your visit?*

Yes

No

Pet's Name*

Species*

Breed*

Age / DOB*

Sex*

Female Intact

Female Spayed

Male Intact

Male Neutered

Color*

Where did you acquire this pet?*

Are Vaccinations Current?*

Yes

No

Unknown

Is your pet microchipped?*

Yes

No

Does your pet have any chronic medical conditions, if yes what?*

Is your pet currently receiving any medications, if yes what?*

Does your pet have any known drug allergies, if yes what?*

Referral Veterinarian

May we contact them for records?

Yes

No

Clinic Name

Clinic Phone #

Do you have X-rays?

Yes

No

Notes

By checking below you certify that you are the owner and or agent of the above animal and have the authorization to consent to treatment if and when it is needed.*

I Agree

Do you want a treatment plan with estimate for your visit?**

Yes

No

All fees are due and payable upon completion of services

For your convenience, we accept payment by cash, check, Care Credit, American Express, Visa, Mastercard, and Discover. Heritage Veterinary Hospital does not provide any billing services.

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 on the pet listed above. Furthermore, I agree to pay for all services rendered at the time the pet is discharged from the hospital or the service is otherwise terminated. I agree to pay for reasonable costs of collection, attorney fees, and court costs in the event that collection efforts become necessary. I agree that the venue of this action will be in the county where the hospital is located. I understand that veterinary service is provided during nighttime hours as necessary in the judgment of the veterinarian in charge. The continuous presence of qualified personnel may not be provided.
*

I have read the payment policy above.

New Client Form

Co-Owner Name (first & last):

Co-Owner Phone Number:

How would you like to be reminded of appointments?*

What is the best time to call about your pet?*

How did you hear about us?*

If you were referred by a client, what is their name?

Do you want a treatment plan with estimate for your visit?*

Patient Information:

Pet's Name*

Species*

Breed*

Age / DOB*

Sex*

Color*

Where did you acquire this pet?*

Are Vaccinations Current?*

Is your pet microchipped?*

Does your pet have any chronic medical conditions, if yes what?*

Is your pet currently receiving any medications, if yes what?*

Does your pet have any known drug allergies, if yes what?*

Referral Information

Referral Veterinarian

May we contact them for records?

Clinic Name

Clinic Phone #

Do you have X-rays?

Notes

Statement of Ownership

By checking below you certify that you are the owner and or agent of the above animal and have the authorization to consent to treatment if and when it is needed.*

Do you want a treatment plan with estimate for your visit?**

Payment Policy