New Client Form - Advanced Veterinary Care of Vestavia

Name(Required)

First Last

Date(Required)

Title Preference

Preferred Pronouns:

Primary Phone(Required)

Secondary Phone

Tertiary Phone

Email(Required)

Address

Street Address Address Line 2 City State ZIP Code

Preferred method for your pets reminders (mark all that apply)

Text and Email

Mail

Secondary Contact

Name

First Last

Relationship

Title Preference

Preferred Pronouns:

Primary Phone(Required)

Secondary Phone

Tertiary Phone

We often give peanut butter as a treat or to administer medication. Do any members of your human household have peanut or nut allergies?(Required)

Yes

How did you hear about our clinic?(Required)

Who may we thank?

Pet Information

List any food or other allergies, current food used, medications used (including current preventatives), and any ongoing health conditions (i.e., liver disease, heart disease, kidney disease, seizures, blindness, deafness, storm anxiety, or aggression towards dogs, cats, and or humans, food aggression).

Species(Required)

Cat

Dog

Pet's Name(Required)

Age/Birthday(Required)

Gender(Required)

Male

Female

Neutered Male

Spayed Female

Breed and Color(Required)

Allergies(Required)

Diet(Required)

Medical/Health Conditions(Required)

Add A Second Pet?

Yes

Species(Required)

Cat

Dog

Pet's Name(Required)

Age/Birthday(Required)

Gender(Required)

Male

Female

Neutered Male

Spayed Female

Breed and Color(Required)

Allergies(Required)

Diet(Required)

Medical/Health Conditions(Required)

Add A Third Pet?

Yes

Species(Required)

Cat

Dog

Age/Birthday(Required)

Gender(Required)

Male

Female

Neutered Male

Spayed Female

Breed and Color(Required)

Allergies(Required)

Diet(Required)

Medical/Health Conditions(Required)

Authorization for Release of Information

This authorization is to obtain records. It will apply to all pets listed on this form, in the same household.

Previous Veterinary Clinic:(Required)

Another name pet's record may be listed under:(Required)

I authorize Advanced Veterinary Care of Vestavia to request the following information for my pet(s):(Required)

Entire Records

Vaccinations Only

Lab Reports Only

Other

I have read and understand the above statements and agree to all terms therein. Electronic Signature(Required)

Requirements and Authorization

To prevent the spread of infectious diseases, all hospitalized and boarded patients must be current on all vaccines (DHPP, Rabies, and Bordetella) and free from external and internal parasites. Signing below authorizes Advanced Veterinary Care to administer the required preventative care if your pet is out of date or the records regarding the above not been provided. For clients who use other vet clinics for their preventative care, AVC prefers paper records hand delivered from the owner or agent of the pet. It is the owner’s responsibility to see that emailed of faxed records are received.

I hereby authorize Advanced Veterinary Care of Vestavia Inc.’s veterinarian(s) to examine, prescribe for and treat the above-described pets. I assume responsibility for all charges incurred in the care of the above animal(s). I understand that the charges will be due at the time of services are rendered. We take Cash, Check, Mastercard, Visa, Discover, American Express, and Care Credit.

All charges must be paid at the time of service. If a payment is not made within 60 days, the account balance will be transferred to our collection’s agency along with a $25.00 processing fee. Make sure your contact information that we have on file is correct. Please note that we are an approved location for the use of Care Credit, a health care credit card. For questions or concerns, please contact Katheren Prinz-Ray or Lindsay Harp. We appreciate your loyal business.

Signature(Required)

Date(Required)

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