New Client Paper Form
Owner Name: __________________________________ Profession: ______________________
* Contact Info (circle primary): Cell _________________ , Work _________________ , Home ________________
Spouse/Additional Owner Name: __________________________ Profession: _______________
* Contact Info (circle primary): Cell _________________ , Work _________________ , Home ________________
Address:_______________________________________________________________________
Primary E-mail Address:
(for reminders, newsletters):_______________________________________________
Whom may we thank for referring you/how did you hear about us?
(friend/vet's name, location, website, vetstreet.com, etc):________________________________________________
Patient Information
Pet Name: _________________________ Pet Name: _________________________
Age/Birthdate: _________ Sex: _______ Age/Birthdate: _________ Sex: _______
Spayed/Neutered: ___________________ Spayed/Neutered: ___________________
Breed: ____________ Color: ____________ Breed: ____________ Color: __________
Previous Veterinary Clinic Name:_____________________________________________________
Phone:____________________ Pet Insurance Provider:___________________________________
All professional and medical services must be paid in full at the time they are rendered.
We do not accept personal checks. _______ (initial here)
We accept credit cards, debit cards and cash.
Please visit our website (www.mountainviewvethospital.com) for details on all of our hospital policies.
As a pet guardian, you will be held liable for the financial responsibility of services that are performed for each pet. Unpaid balances will be recovered as deemed appropriate by Mountain View Hospital management and may incur a $30.00 administration fee. A 1.5% monthly interest fee will be charged on all unpaid balances.
I understand and abide by the above statements.
Signature:__________________________________ Date:_______________________
We often use patient pictures for our website or Facebook. We may also use medical cases for veterinary journals or publications. Your initials give MVVH authorization to release portions of your pet's medical history and record, including personal recollections, radiographs, photographs, videotape images or other images for use in the print media, on a brochure, the MVVH website, social media outlets, and veterinary publications. You also agree not to file any claim for revenue or lawsuit for damages against this veterinary practice with respect to the release of this information.
Approve: _______ (initial here) Decline: _______ (initial here)
* Contact Info (circle primary): Cell _________________ , Work _________________ , Home ________________
Spouse/Additional Owner Name: __________________________ Profession: _______________
* Contact Info (circle primary): Cell _________________ , Work _________________ , Home ________________
Address:_______________________________________________________________________
Primary E-mail Address:
(for reminders, newsletters):_______________________________________________
Whom may we thank for referring you/how did you hear about us?
(friend/vet's name, location, website, vetstreet.com, etc):________________________________________________
Patient Information
Pet Name: _________________________ Pet Name: _________________________
Age/Birthdate: _________ Sex: _______ Age/Birthdate: _________ Sex: _______
Spayed/Neutered: ___________________ Spayed/Neutered: ___________________
Breed: ____________ Color: ____________ Breed: ____________ Color: __________
Previous Veterinary Clinic Name:_____________________________________________________
Phone:____________________ Pet Insurance Provider:___________________________________
All professional and medical services must be paid in full at the time they are rendered.
We do not accept personal checks. _______ (initial here)
We accept credit cards, debit cards and cash.
Please visit our website (www.mountainviewvethospital.com) for details on all of our hospital policies.
As a pet guardian, you will be held liable for the financial responsibility of services that are performed for each pet. Unpaid balances will be recovered as deemed appropriate by Mountain View Hospital management and may incur a $30.00 administration fee. A 1.5% monthly interest fee will be charged on all unpaid balances.
I understand and abide by the above statements.
Signature:__________________________________ Date:_______________________
We often use patient pictures for our website or Facebook. We may also use medical cases for veterinary journals or publications. Your initials give MVVH authorization to release portions of your pet's medical history and record, including personal recollections, radiographs, photographs, videotape images or other images for use in the print media, on a brochure, the MVVH website, social media outlets, and veterinary publications. You also agree not to file any claim for revenue or lawsuit for damages against this veterinary practice with respect to the release of this information.
Approve: _______ (initial here) Decline: _______ (initial here)