New Client Form

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Client-Patient Information Form

Thank you for giving us the opportunity to care for your pet(s). Please help us meet your needs better by taking a few moments to complete each of the information sheets.

Date

MM slash DD slash YYYY

Owner’s Name*

First Last

Co-Owner’s Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Contact Phone Number*

Co-Owner’s Contact Number

Work Phone Number

Co-Owner’s Work Number

Email*

Driver’s License No.

Employer

Co-Owner’s Employer

Preferred Method of Contact:*

Cell Phone

Home Phone

Work Phone

Text

How did you first hear of our hospital?

Personal Recommendation

Our Website

Drove by / Sign

Previous Client

Google

Facebook

Yelp

Another Business

Other

Whom may we thank?*

If Another Business*

Pet Information #1

Name*

Species*

Feline (cat)

Canine (dog)

Exotic

Breed (type)*

Color*

DOB / Age*

Sex*

Male Intact

Male Neutered

Female Intact

Female Spayed

Prior Illness:

Prior surgery not including altering:

Date of last Vaccines & Clinic done at:

Vaccine

Date

Clinic

Pet Insurance Company

Pet Information #2

Name

Species

Feline (cat)

Canine (dog)

Exotic

Breed (type)

Color

DOB / Age

Sex

Male Intact

Male Neutered

Female Intact

Female Spayed

Prior Illness:

Prior surgery not including altering:

Date of last Vaccines & Clinic done at:

Vaccine

Date

Clinic

Pet Insurance Company

Pet Information #3

Name

Species

Feline (cat)

Canine (dog)

Exotic

Breed (type)

Color

DOB / Age

Sex

Male Intact

Male Neutered

Female Intact

Female Spayed

Prior Illness:

Prior surgery not including altering:

Date of last Vaccines & Clinic done at:

Vaccine

Date

Clinic

Pet Insurance Company

Notification/ Agreement

To prevent the spread of infectious diseases and parasites, hospitalized and medical boarded animals must be current on all vaccines and free of internal and external parasites. I authorize the New Prairie Small Animal Clinic to provide vaccines and parasite control as needed for my pet. I am financially responsible for the patient(s) described above and agree to pay all fees incurred. I understand that any medical or surgical procedure is attended by some risk and that it is not possible to guarantee that successful outcome of any such procedure. This agreement is in force indefinitely from this date unless notify New Prairie Small Animal Clinic in writing on the contrary.

Authorization for release of medical records

I authorize the New Prairie Small Animal Clinic to acquire all medical or surgical records from my previous veterinarian and /or send such information to any veterinarian and/or pet boarding/ grooming facility as requested by us or them.

Appointment Cancellation/ Late & Reschedule Policy Agreement

New Prairie Small Animal Clinic is committed to providing all our patients with exceptional care. When a patient cancels without giving enough notice, they prevent another patient from being seen.

If you need to reschedule an appointment, please give our office a call at 219-778-4458 the day prior to your scheduled appointment to notify us of any changes or cancellations. If after 2 missed/canceled appointments, you will be charged a deposit before scheduling another appointment. If you miss/cancel that appointment your deposit will be forfeited and another deposit will be required to schedule another appointment.

If you are more than 10 minutes late to your scheduled appointment you will be asked to reschedule the appointment or you will be seen as a work in (work in can mean anytime from your original appointment to the time we close) and be charged a work-in fee.

PHOTO CONSENT

I grant to New Prairie Small Animal Clinic, its representatives and employees the right to take photographs of me/ or my pet, and to copyright, use and publish the same in print and or electronically. I agree that New Prairie Small Animal Clinic may use such photographs of me and or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content.*

I GIVE permission to New Prairie to use photos of me and or my pet

I DO NOT permission to New Prairie to use photos of me and or my pet

Payment Information

Payment is due in full at the time services are rendered
This office does NOT do any billing, we do NOT offer payment plans

We accept the following forms of payment:

Visa
MasterCard
Discover
American Express
Care Credit
Cash
Scratchpay

We accept personal checks with a valid Driver’s License or Social Security Number. There is a $25 fee for all returned checks. Please print and sign below that you are taking responsibility for full payment of treatment and services for the pets you are bringing in to New Prairie Small Animal Clinic, at the time they are treated. If you are not the individual who is financially responsible for these pets, by signing this form you are stating that you have made prior arrangements with the individual who is. I agree to absolve the New Prairie Small Animal Clinic, veterinarian, and staff employed by the practice of any financial consequences that may occur between you and the other individual you have made prior arrangements with.

Print Name*

Date*

MM slash DD slash YYYY

Signature*

Comments

This field is for validation purposes and should be left unchanged.

Complete Online:

Client-Patient Information Form

Pet Information #1

Pet Information #2

Pet Information #3

Notification/ Agreement

Authorization for release of medical records

Appointment Cancellation/ Late & Reschedule Policy Agreement

PHOTO CONSENT

Payment Information

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