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New Client Registration
Primary Owner
*
First
Last
Co-Owner
First
Last
DOB
*
Date Format: MM slash DD slash YYYY
Previous Client
*
Yes
No
Previous name
Mailing address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Is mailing address the same as physical address?
*
Yes
No
Physical address
Street Address
City
State / Province / Region
ZIP / Postal Code
Owner's Phone
*
Landline
Co-Owner's Phone
Landline
Email
*
Authorized agent
First
Last
Phone
Relationship
Authorized to
Full Authorization to make any medical decisions
Authorization to make emergency medical decisions when Owner(s) cannot be reached
Authorized to make appointments and bring pet to appointments
Authorized to pick up medications
Other
If other please specify:
Would you like to add another authorized agent?
Yes
No
Authorized agent
First
Last
Phone
Relationship
Authorized to
Full Authorization to make any medical decisions
Authorization to make emergency medical decisions when Owner(s) cannot be reached
Authorized to make appointments and bring pet to appointments
Authorized to pick up medications
Other
If other please specify:
Would you like to add a third authorized agent?
Yes
No
Authorized agent
First
Last
Phone
Relationship
Authorized to
Full Authorization to make any medical decisions
Authorization to make emergency medical decisions when Owner(s) cannot be reached
Authorized to make appointments and bring pet to appointments
Authorized to pick up medications
Other
If other please specify:
Pet Info
Pet’s Name
*
Species
*
Breed
*
Pet’s DOB
Date Format: MM slash DD slash YYYY
Gender
*
Male, neutered
Male, not neutered
Female, spayed
Female, not spayed
Color
*
Previous Veterinary Clinic
*
Enter no/unknown if you dont know or dont have one
Phone
Add one more pet?
*
Yes
No
Pet’s Name
Species
Breed
Pet’s DOB
Date Format: MM slash DD slash YYYY
Gender
Male, neutered
Male, not neutered
Female, spayed
Female, not spayed
Color
Previous Veterinary Clinic
Phone
Add one more pet?
Yes
No
Pet’s Name
Species
Breed
Pet’s DOB
Date Format: MM slash DD slash YYYY
Gender
Male, neutered
Male, not neutered
Female, spayed
Female, not spayed
Color
Previous Veterinary Clinic
Phone
Consent
*
I give permission to my prior DVM/clinic (s) listed above to release my pets’ medical records to HVMG.
Cancelation, No-show, and Late Policies
• I understand that I will be charged a deposit to secure my first appointment.
• I understand that if I "no-show" this appointment, I will lose the deposit.
• I understand that if I am late to an appointment, I may be asked to reschedule.
Our commitment to providing the best care to all our patients is our priority. We understand that situations arise that may interfere with your appointment.
Please tell us as soon as you can if you cannot keep an appointment or are running late.
Financial Policies
• All procedures must be fully paid for when the services are rendered.
• Payment methods: Cash, credit cards, personal checks, and Care Credit.
• Payment plans are not available.
• Surgery will be paid in full at check in.
Estimates
When possible, we will provide an estimate of the predicted charges for your pet’s care. Diagnostic tests or a change in your pet’s condition may cause changes to your pet’s treatment plan. If the cost of care significantly exceeds our estimate, we will try to contact you to discuss treatment options. Please be available for calls.
Pet Insurance
We highly recommend getting pet insurance. It is affordable and plans can be obtained for all ages. For more information about plans, visit our website at humboldtvet.com For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier.
Returned Checks
The balance plus fees must be paid within 3 days of notice. If an account becomes delinquent for more than 30 days, additional fees will be assessed. Severely delinquent accounts will be sent to an attorney for litigation and credit bureau reporting if the hospital chooses.
Photo Release
We have social media accounts, and we love to take pictures of patients to share with others. We will not post or release any personal information.
Permissions
*
I allow full permission
I decline all permissions
Consent
I am the owner of the animal listed on this form and consent to treatment.
By signing, you acknowledge that you fully understand the above policies and their conditions.
Δ
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Contact Us
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