New Client Information Form - Chester Valley Veterinary Hospital

Name *

First

Last

Phone *

Spouse/Secondary Name

Spouse Phone

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Physical Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Check all that apply

Military
Policeman
Fireman
Senior Citizen

How did you hear about us?

Yellow Pages
Internet
Drive by/Sign
Friend

Website

(Please specify the website you found us on)

Friend's Name *

(Please specify the referrer’s name so we can send a thank you gift)

Pet's Name *

Date of Birth or Age

Species

Breed

Sex *

Male
Female

Color/Description

Fixed *

Yes
No

Microchip Number

Previous Veterinary Office/Vaccine Clinic

Photo/Video Release: I hereby grant permission to the rights of my pet’s image, likeness and sound of his/her voice as recorded on audio or video without payment or any other consideration to Chester Valley Veterinary Hospital. I understand that my pet’s image may be edited, copied, exhibited, published or distributed and waive any right to royalties or other compensation arising or related to the use of my pet’s image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area. *

Permission Granted
Permission Denied

Treatment Authorization/Payment Authorization: I hereby authorize Chester Valley Veterinary Hospital’s doctor(s) and staff to examine my pet(s) and to discuss findings with me or an authorized representative. I understand that I am entitled to an estimate of charges for the care and treatment of my pet(s). I am also aware that regardless of my decision to proceed with the estimated treatment or not I am responsible for an exam fee. I hereby consent to the care and treatment of my pet(s) by the staff at Chester Valley Veterinary Hospital. I give my permission to the administration of anesthesia and surgical procedures as seen fit by the physical in the event of an emergency as well as in the treatment of my pet(s). I understand that an itemized receipt will be presented to me upon the release of my pet(s). I take full financial responsibility of all incurred charges for my pet(s). I also understand that full payment is expected before said pet(s) is released to me. I fully understand that any pet(s) brought to Chester Valley Veterinary Hospital by the above person/persons or authorized representative will be considered abandoned, if the animal(s) is not collected within 10days of written notice to the above address. Upon which time Chester Valley Veterinary Hospital has the rights to adopt it out, sell, or euthanize without prejudice to its claims for fees or services rendered. *

I have read and understand

No Show/Cancellation Policy: I hereby understand that Chester Valley Veterinary Hospital requires a 24 hour notice to reschedule or cancel an appointment. Failure to call and cancel an appointment or arriving 15 minutes late to an appointment will be deemed a “no show”. A cancelled or no show appointment will incur a fee at Chester Valley Veterinary Hospital’s discretion and can result in the refusal of service at this practice. *

I have read and understand