Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Mobile Phone Number: *

Does this phone accept text messages? *

Yes
No

Your primary email for the doctor to send your pet's report and discharge instructions *

Other Responsible Party (second pet parent in home, or if a single pet parent family your emergency contact person) *

First

Last

Second Party's Mobile Phone Number: *

Second Party's Email:

Does this phone accept text messages? *

Yes
No

How did you first learn of our hospital?

Whom may we thank? *

If Other, please explain. *

Previous Veterinary Clinic Name/Names: *

Previous Veterinary Clinic's Town and State: *

Pet's Name *

Pet Species *

Dog
Cat

Birthdate or Approximate Age *

Breed *

Color *

Sex *

Male
Neutered Male ("fixed")
Female
Spayed Female ("fixed")

Is your pet microchipped? *

Yes
No

If yes, what is your pet's chip number? *

Show us your friend and upload a photo here! We use profile pictures in our medical records and would love a photo of them being super cute at home!

Click or drag a file to this area to upload.

Our instagram handle is @healingpawsveterinary - does your pet have an Instagram handle? *

Yes
No

If yes, What is your pet's IG handle? *

We can't wait to meet your pet! What makes them a great companion and friend? *

Please upload any medical records or vaccine history that you have for your pet here. This information helps our doctors and medical team do a more thorough job in personalizing your pet's care! Please note -we prefer to have the actual medical records in addition to the vaccination history. Thank you!

Click or drag files to this area to upload. You can upload up to 10 files.

What is the first appointment type you need to schedule for your friend? (Check all that apply) *

If other, please specify

Do you have any other cats or dogs in your household? *

Yes
No

When choosing a veterinarian for your pet, what is important to you? *

When choosing a pet food, what is important to you? *

At Healing Paws Veterinary Care, we recommend regular examinations, vaccinations, commercially prepared balanced pet foods, parasite prevention, regular dental hygiene procedures, and, when needed, collaboration with board-certified veterinary specialists to ensure your pet receives the very best care. Please select one of the following options. *

I agree with the above recommendations. I commit to bringing my pet for regular examinations, listen to the doctors recommendations, ask questions as I need to, and work as a team with the staff at HPVC to create the best plan for my pet and family.
I have some questions about these recommendations and would like to be contacted by a member of the HPVC team. Together we will determine if this type of veterinary care is appropriate for my pet.
I only want basic veterinary care for my pet.
Other

If other, please specify

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 can be. Healing Paws will never share images of pets during the last moments of their lives, and we use discretion in the images taken and shared. We only use pet names and not owner names in our content. By signing below, I hereby give Healing Paws the right to use the name, video, and photographs 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, understand and give permission to the staff of Healing Paws Veterinary Care to use images of my pet/pets.
I do not give permission to the staff of Healing Paws Veterinary Care to use images of my pet/pets.

Professional fees are due in full at the time of services rendered.

Payment Options: Cash, checks drawn from a local bank, debit cards, VISA, MasterCard, and Scratch Pay only

Deposits: Non-refundable deposits are required for illness appointments, first new client visits, in-patient appointments, and anesthetic procedures.

Estimates: At your request, we will gladly discuss the cost of services and/or prepare a written estimate for recommended procedures and treatments. Our goal is to provide your pet with thorough care that also fits your family's needs. We believe in recommending the best for your pet and your family - if you desire an estimate, please request one before authorizing procedures being performed.

Cancelled Appts: We ask that if you must cancel or reschedule your appointment, you do so greater than 24 hours of your appointment (72 hrs for anesthesia appointments). With the exception of emergency, management deemed extenuating circumstances all appointments that are canceled or rescheduled within 24 hrs of the appointment time (72 hrs for anesthesia appointments) or are no shows will be assessed a cancellation fee. The cancellation fee must be paid in full before rescheduling the next appointment in these situations.

Returned Checks: We charge a $100 fee for returned checks. This returned check charge and the client balance must be paid in full before scheduling any further appointments.

Failure to Pay: 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.

I have read, understand and agree to the above statement *

I acknowledge.

I represent that any information I provided above is accurate and agree to the terms set forth herein. I understand that payment in full 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.

Please check below. *

I have read, understand, and agree to the above statement

I am the legal owner or responsible party seeking veterinary care for the pet/pets identified and I certify that I am eighteen years of age or over. *

I have read, understand, and agree to the above statement

Today's Date *

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