Client Information

Name *

First

Last

Spouse/Co-Owner's Name

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

How did you hear about us? *

Whom may we thank for the referral? *

If other, please specify *

Primary Phone *

Secondary Phone

Email *

Occupation

Employer

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Spouse/Co-Owner's Primary Phone

Spouse/Co-Owner's Secondary Phone

Spouse/Co-Owner's Email *

Spouse/Co-Owner's Occupation

Spouse/Co-Owner's Employer

Spouse/Co-Owner's Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Name of individual authorized to pick up the patient:

First

Last

Name of individual authorized to pick up the patient:

First

Last

Name of individual authorized to pick up the patient:

First

Last

Treatment Authorization

I understand that an exam is required for any treatments to be discussed or performed by the doctors and staff of Village Vet Animal Clinic. I hereby authorize Village Vet Animal Clinic to perform medical and initial diagnostics/surgical procedures on my pet as required for diagnosis and treatment. I understand that I can terminate treatment at any time by contacting the doctors and assistants. *

I have read and understand

Financial Policy

Payment is due as services are rendered. Village Vet Animal Clinic does not accept billing of any kind.For hospitalized cases, a deposit may be required in advance. You may pay by cash, personal check (with ID), accepted credit cards, including CareCredit, and accepted trade organizations. In order to avoid misunderstandings, please let us know immediately if you have any concerns regarding these policies.All returned checks will incur a charge of $25.00 and may be referred to the District Attorney for collection. *

I have read and understand

I understand that I (the owner or agent) am financially responsible to Village Vet Animal Clinic for all charges relating to this patient. I have read and agree to the treatment authorization. I have also read and accept the financial obligations. *

Clear Signature

Date *

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Client Intake Form