testing New Client Form Welcome! We value our clients and patients and look forward to being of service to you.Owner’s First, Last Name: First Last Additional Owner First, Last Name: First Last Email Address: Home Address: Street Address City State / Province / Region ZIP / Postal Code Primary Phone Number:Alternate Phone Number:Preferred Method of Contact (Phone, Email, Text):Pet’s NameMale or Female?MaleFemaleSpayed or Neutered?YesNoBreedColorBirth Date or Approximate AgePet’s NameMale or Female?MaleFemaleSpayed or Neutered?YesNoBreedColorBirth Date or Approximate AgePet’s NameMale or Female?MaleFemaleSpayed or Neutered?YesNoBreedColorBirth Date or Approximate AgePet’s NameMale or Female?MaleFemaleSpayed or Neutered?YesNoBreedColorBirth Date or Approximate AgeName of Previous Vet:Do You Give Us Permission to Obtain Previous Records?YesNoHow Did You Hear About Us?:We’d love to share your pet(s)’ stories and images on our social media! We never share your full name or personal information. Do we have your permission to share their stories and images on our pages? (Initial One)YesNoYes, share away!:No, I prefer not to:We kindly ask you bring dogs in on leashes and cats in carriers for the safety of all our patients and staff. We have leashes available to borrow at the front desk upon request. If you must cancel an office visit appointment, we ask for 24 hours’ notice. If cancelling a surgical appointment, we ask for 48 hours’ notice. Repeated cancellations or no shows for appointments are subject to a cancellation fee and will require a non-refundable deposit for future appointments. Up-todate vaccinations are required by Wintermere Pointe Animal Hospital before we are able to admit any animal for surgery or other procedures. These measures are taken to protect the well-being of all animals within our hospital. For dogs, this includes Rabies, DAPPv, and Bordetella vaccines. For cats, this includes Rabies and FVRCP vaccines. If your pet(s) are not up to date on these vaccines, please ask how we can bring them up to date for you. Treatment Consent: I hereby authorize the veterinarian to examine, prescribe for and/or treat the above described pet(s). I assume responsibility for all charges incurred in the care of these pet(s) and understand payment is always due in full at the time of service. I recognize financial concerns should be discussed prior to diagnostics and treatment. We can provide you with an estimated cost for services during your visit. We cannot give an estimate over the phone for non-routine procedures without assessing your pet face-to-face; this includes dental procedures. For your convenience we accept Apple Pay, Visa, Mastercard, American Express, Discover, and cash. We do not accept checks. I affirm the above information is correct and that I am the owner or authorized agent of the pet(s) listed above.SignatureDate
