Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together. Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.

Primary Owner *

First

Last

Pet Owner DOB *

We may send home controlled substances for your pet’s pain, the state of Indiana requires pet owner date of birth.

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Please enter a valid phone number.

Home Phone *

Please enter a valid phone number.

Email *

example@example.com

By signing this document, you are agreeing to sole ownership of pet(s) and take full financial responsibilty of the pet's health care needs. All decisions for pet(s)' health care, including end of life, will be your responsibility. If you agree to share all responsibilities with another person, please add their name with their signature.

To change the ownership of listed pet(s), all parties with ownership rights will have to sign another agreemant.

Signature

Co-owner Name *

First

Last

Co-owner Cell Phone *

Please enter a valid phone number.

Signature

Layout

Layout (copy)

If personal Referral, is there someone we can thank?

If other, please specify:

Pet #1 Information

Name

Breed (If Known) *

Neutered/Spayed? *

Yes
No
Unknown

Species

Color *

Sex *

Male
Female

Are there any previous medical conditions we should be aware of? If yes, please explain: *

Pet #2 Information

Field #106 (copy)

Name

Breed (If Known)

Date of Birth or Age (If known)

Neutered/Spayed?

Yes
No
Unknown

Species

Color

Sex

Male
Female

Are there any previous medical conditions we should be aware of? If yes, please explain:

Pet #3 Information

Name

Breed (If Known)

Date of Birth or Age (If known)

Neutered/Spayed?

Yes
No
Unknown

Species

Color

Sex

Male
Female

Are there any previous medical conditions we should be aware of? If yes, please explain:

Financial Agreements

Payment in full is required at the time of service. We have several payment options available for our patients. They allow patients to receive veterinary care and still remain within the owner's budget.We accept VISA, MASTERCARD, DEBIT CARDS, CASH, PERSONAL CHECKS, AND SCRATCH PAY* (A FINANCE PLAN *subject to individual approval). We apply a 1.5% or $10 monthly service charge for any charges not paid in full over 30 days.

Required *

I have read the above

Cancellations

We ask that should it become necessary to reschedule or cancel an appointment, please notify our office at least 24 hours prior (2 full business days for surgery/dental procedures) in order to allow us the opportunity to offer the reserved appointment time to another patient. We understand that emergencies occur, however, short notice cancellations and NO SHOWS affect all of our patients resulting in time lost and treatment delayed. When a short notice cancellation or NO SHOW occurs, there will be an administrative fee charged for each appointment scheduled in the amount of $85 for appointments and $150 for surgical/dental procedures. Surgery/dental procedure appointments are premium time and as such so is the administrative fee! LATE ARRIVALS that prevent sufficient time to complete the scheduled appointment will be rescheduled and may be subject to a charge. We value our client's time and do everything possible to see each patient at their appointed time. However, please be aware there may be times when emergencies prevent us from seeing a patient at their exact scheduled appointment time. We will give you the option of staying for your appointment or to reschedule for a more convenient time.

Required *

I have read the above

Privacy Information Act

The Indiana Veterinary Practice Act states that an animal’s medical records and condition is confidential and may not be shared with anyone other than the pet’s owners, veterinarians involved in the care and treatment of the pet or law enforcement. This would include grooming, boarding, humane society facilities or pharmaceutical companies for coupons unless otherwise specified.

Required *

I give permission
I do not give permission

Release of Information for Media or Website Publication*

After an explanation of its intended use, I authorize the staff at this veterinary practice to release portions of my pet’s medical history and record, including personal recollections, radiographs, photographs, videotape images or other images to use on any of the following media entity(ies): Facebook, Twitter, St. Johns Animal Clinic Website.

Required *

I give permission
I do not give permission

Date *

Client Information Form