Owner Contact Information

Your Name *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

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Primary Phone *

Alternative Phone

Email *

Would you like to receive text messages? *

Would you like to receive emails? *

Are you a new client? *

If you are a new client, how did you hear of us? *

Would you like to add a co-owner or authorized agent? *

Yes
No

Co-Owner or Authorized Agent Contact Information

Co-Owner name *

Address

Address Line 1

Address Line 2

City

State

Zip Code

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Email *

Pet/s Information

Pet Name *

Type of Pet *

Please specify the type of pet *

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Breed *

Date of Birth or Age *

Sex *

Reason for Today’s Visit: *

Did your pet have a previous Veterinarian or Clinic? *

Yes
No

What is the name of your pet's previous Veterinarian or Clinic? *

May we contact them for medical history of your pet? *

Yes
No

Does the patient have any allergies? *

Yes
No

What are the patient's allergies? *

Agreements & Authorizations

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

Yes
No

May we use your pet’s photo? *

Yes, I agree
No, I do not agree

CVHC Social Media/Photo Release

Please type your name below to authorize CVHC permission to use photos of your pet on social media or for advertising purposes. *

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Last

*You may change your decision at any time

CVHC Financial Policy *

I have read and agree to the financial policies described.

We at CVHC understand that this may be a difficult time for you and your pet. We realize a visit to our clinic is unplanned and the associated fees are unexpected. We would like to offer the following options to assist you:

Cash
Cash payments are gladly accepted.

Personal Checks (NO BUSINESS CHECKS)
We accept personal checks only with a current driver’s license. A fee of $25.00 will be assessed on all returned checks. When you provide us with a check as payment you authorize us to either use information from your check to make a one-time electronic fund transfer from your account or to process the payment as a check transaction.

Credit Cards
We accept: VISA, MasterCard, American Express, and Discover

Care Credit
CareCredit is a credit card dedicated to health care. It involves a no-cost application, which can be processed immediately. We offer a 6 month no interest payment plan. Please ask one of our staff for additional information or an application, if interested.

Veterinary Pet Insurance
We work with all Veterinary Insurance Providers and can supply you with any information or records you require in order to obtain reimbursement of funds spent on your pet during his/her CVHC visit.

Payment in full is due at the time of services. For hospitalized cases, a deposit is required in advance. The balance is due upon discharge from the hospital.

If you should have any questions on the above payment options or if we can be of further assistance to you, please ask one of our administrative members.

Please type your name to agree to CVHC's financial policy *

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Last

Treatment Authorization and Information/Photo Release *

I have read and agree.

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 Health 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 payment for diagnostic tests and treatment that I authorize in writing or verbally will be due at the time 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 at the agreed time.

Case information and/or photos may be used in teaching, continuing education, and veterinary literature. I authorize the release of case/patient information for such purposes. Patient confidentiality will be maintained. In the event of ownership transfer, I authorize the release of medical information to the new owner of this animal.

Please type your name to agree to CVHC's Treatment Authorization and Information/Photo Release *

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Today's Date *

NEW PATIENT FORM

New Patient Form

Owner Contact Information

Co-Owner or Authorized Agent Contact Information

Pet/s Information

Agreements & Authorizations

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