New Client Form - Healing Paws Veterinary Care

Name *

First

Last

Other Responsible Party

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Telephone *

Does this number accept texts? *

Yes
No

Secondary Telephone

Does this number accept texts? *

Yes
No

E-mail *

(for doctor and boarding communication - please do not use your spam address)

Spouse/Other E-mail

Your Driver’s License Number *

Your Driver’s License State *

Emergency Contact (Name and Phone Number) *

How did you first learn of our hospital: *

If recommended by a friend or acquaintance, what is their name so that we may thank them?

Previous Veterinary Clinic Name

Previous Veterinary Clinic Address

Previous Veterinary Clinic Phone Number

PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. DEPOSITS MAY BE REQUIRED FOR PETS BEING ADMITTED. Payment Methods: We accept cash, checks drawn from a local bank, debit cards, VISA, MasterCard and Scratch Pay. Fees: We charge a 5% Third Party Administration Fee for the use of Scratch Pay and a $50 fee for returned checks. Furthermore, in the event you refuse or otherwise fail to make payment owed for services rendered by us in caring for your pet, you are responsible for any and all costs of collection incurred by us, including attorney’s fees, to collect payment(s) from you. Estimates: At your request, we will gladly discuss cost of services and/or prepare a written estimate for recommended procedures and treatments. *

I have read and understand.

Acknowledgment and Agreement: I represent that any information I provided above is accurate and agree to the terms set forth herein. I understand that payment is due to Healing Paws Veterinary Care, Inc. (“Healing Paws”) at the time services are rendered. I authorize Healing Paws to collect payment if I do not pay in accordance with this agreement, and agree that I am responsible for all costs of collection, including, but not limited to, attorney’s fees and court costs. I have been informed that estimates for recommended services/procedures are available upon my request. I further understand that all services performed on my pet will be invoiced according to Healing Paws procedures. *

I have read and understand.

PHOTO/ NAME RELEASE: Healing Paws likes to use images of our client’s pets to demonstrate the care and attention that they receive here. When pets are happy and calm during treatment and care, it helps other pet owners to see how enjoyable veterinary care, boarding, and grooming can be. Healing Paws will never share images of pets during the last moments of their lives and uses discretion in the images that are taken. By signing below, I hereby give Healing Paws the right to use the name, video and photograph of any of my pets in connection with its website and any promotional materials in any and all media, including, but not limited to, printed material, internet, social media, and film for display, public relations and marketing. I hereby acknowledge receipt of adequate consideration and waive the right (i) to charge or be compensated for the use of the pictures, and my pet(s)’s name(s) and (ii) to inspect or approve the images prior to any form of usage. I understand that the images may be modified to use as design elements

I have read and give permission.

What is your pet's Instagram page handle?

Digital Signature *

Today's Date *

We love new patients!