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(941) 391-5251
(941) 391-5251
Request an Appoinment
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New Client Form
Welcome, New Clients!
Take a moment to let us know a bit more about you and your pet.
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Company
This field is for validation purposes and should be left unchanged.
Pet Owner Information
Date
MM slash DD slash YYYY
Owner:
*
First*
Last*
Spouse/Co-Owners Name
*
First
Last
Contact:
Cell
*
Home
Work
Email Address
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Address:
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Street*
City*
State*
Zip Code*
All Fees Are Due At the Time Services Are Rendered We accept: Cash/Check - Visa - MasterCard - Discover - Care Credit (with valid ID, cardholder must be present)
Patient Information
Pet's Name
Breed
Color
Sex
Male
Female
Age
Spayed/Neutered?
Yes
No
Allergic Reactions
Yes
No
Previous Veterinarians Name
Previous Veterinarians Phone
List dates boosters were last given:
Is your pet currently on a special diet or medication?
Is your pet on Heartworm prevention(What Kind)?
Is your pet on Flea prevention(What Kind)?
Is your pet on Tick prevention(What Kind)?
Our pet(s) is
Indoor Only
Outdoor Only
Goes On the Patio
Equally Indoor/Outdoor
A Child's Pet
What food does your pet eat?
Any previous illnesses or surgeries?
Any allergies to vaccinations or medications?
Existing medical conditions?
Behavior problems?
What are your primary concerns?
How did you become aware of our clinic?
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Drove By
Website
Personal Recommendation
Phone Book
Other Clinic
PLEASE READ OUR FINANCIAL POLICY CAREFULLY Our policy is to provide you with a written estimate of fees for in-clinic treatment, surgery, hospitalization and/or emergency care. Your signature on that written estimate gives Groves Veterinary Clinic authorization to provide medical care. The estimate is only an approximation of cost and may not include any treatments that may be deemed necessary upon examination and commencement of the included treatments. If additional treatments are deemed necessary we will do our best to inform you prior to providing that treatment. Estimates are valid for thirty days from the date they are created. In the event of an emergency you authorize Groves Veterinary Clinic to provide the necessary life saving medications, treatment and resuscitation with the understanding that this will be an expense above the written estimate. If you do not want life saving resuscitation to be performed to revive your pet in the event of cardiac or respiratory arrest please inform a staff member and we will have you sign a Do Not Resuscitate release. All fees are due at the time services are rendered and will be collected upon your approval of treatment. If your pet is admitted to the hospital, all accounts must be kept current daily throughout the period of hospitalization and all charges will be due prior to the discharge of your pet. All services, medications and products are nonrefundable. Radiographs are retained in our office as part of your pets medical record, a copy will be provided at the clients request but the original is owned by the practice. Record and radiograph duplication fees may be charged. OUR POLICY CONCERNING ABONDONED ANIMALS If you do not pick your pet up within ten (10) days of its release date and pay all charges due, your pet will be considered abandoned. Your total bill which is to include the treatment charges, service charge of 1.5% of the unpaid balance per month plus the ten additional days of hospitalization will be turned over to an outside agency for collection and may be placed on your credit record. Should collection proceedings be required to collect an outstanding debt you will be responsible for all additional expenses incurred to collect the debt including the collection agency fees, attorney fees and any associated court costs. Should this become necessary you may also be discharged from the practice. OUR POLICY CONCERNING RETURNED CHECKS AND UNPAID BALANCES For each returned check, a fee of $30.00 will be assessed. For any unpaid balances there will be a service charge of 1.5% of the unpaid balance per month. Failure to pay for medical services delivered in good faith may cause your account to be turned over to an outside agency for collection and may be reported on your credit record. Should collection proceedings be required to collect an outstanding debt you will be responsible for all additional expenses incurred to collect the debt including the attorney fees, collection agency fees and any associated court costs. Should this become necessary you may also be discharged from the practice. PHOTOGRAPH RELEASE Groves Veterinary Clinic has various internet and print advertisements. These advertisements will include articles and photos involving our patients (your pets). Your identity will be protected; no owner’s names will be placed on any advertisement. There may be times that our patients (your pets) name will be used and facts about their medical case. For these reasons we are asking for your permission to use your pets photograph's on our advertisements, articles, websites and educational material.
Policies
*
I agree to the policies.
I have read and understood the above policies and request treatment for my pet in accordance with these policies. I assume all financial responsibility for all charges incurred, including those above the estimate, and agree to pay all costs of collection and fees in the event of non-payment. I grant permission to use my pets photographs on all of Groves Veterinary Clinic advertisements, articles, websites and educational material.
SMS Consent
I agree to receive recurring automated messages about pet care, appointment reminders, marketing communications, and offers to the mobile number provided. Your consent is not required, and you may opt out at any time by replying STOP. Msg & data rates may apply. Message frequency may vary.
I agree to receive SMS communications.
Email Consent
I agree to receive marketing offers and updates via your preferred/primary email. You'll still receive services and account related emails if you do not check the box.
I agree to receive email communications.
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Date
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