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 *

Secondary Telephone

E-mail *

Spouse/Other E-mail

Your Driver’s License Number *

Your Driver’s License State *

Emergency Contact (Name and Phone Number) *

How do you prefer to be notified of reminders? *

Phone Message
Email
Post Card

How did you first learn of our hospital? We would like to thank any individual who referred you. *

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, and MasterCard. Fees: We charge 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 procedure. 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 INCURRED BY HEALING PAWS TO COLLECT PAYMENT, IF I DO NOT PAY IN ACCORDANCE WITH THIS AGREEMENT. I HAVE BEEN INFORMED THAT ESTIMATES FOR RECOMMENDED SERVICES/PROCEDURES ARE AVAILABLE UPON REQUEST. I FURTHER UNDERSTAND THAT ALL SERVICES PERFOMRED ON MY PET WILL BE INVOICED ACCORDING TO HEALING PAWS’ INTERNAL PROCEDURES. I REPRESENT THAT THE INFORMATION ABOVE IS ACCURATE AND AGREE TO THE TERMS SET FORTH HEREIN. *

I have read and understand.

PHOTO/ NAME RELEASE: By signing below, I hereby give Healing Paws Veterinary Care 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 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 use of the pictures, and my pet(s)’s name 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.

Digital Signature *

Today's Date *

We love new patients!

Save time and complete your new patient and client information form online. If we have any additional questions, we’ll be sure to reach out!