New Client Form Thank you for giving us the opportunity to care for your pets!!Client Name* First Last Spouse's NameAddress Street Address City State / Province / Region ZIP / Postal Code Cell Phone*Spouse Cell PhoneEmail Work PhonePlace of EmploymentDate of Birth MM slash DD slash YYYY Driver's License # w/ state*License Expiration Date MM slash DD slash YYYY We take a NON-REFUNDABLE deposit to cover the exam/consultation fee to schedule the initial appointment.I understand and agree that if I change my mind about the policies or disagree after paying the deposit, it is still non-refundable. This fee/deposit will be applied as a credit to charges that occur during my pet’s first visit.Late Cancellations / No-Shows 24 business hours' notice is required to reschedule or cancel appointments and 3 days’ notice for surgical procedures. I understand that I will forfeit this payment if I do not show for the appointment or do not follow the cancellation requirements. How did you become aware of our Clinic? Please check ALL that apply* New Resident Letter Website Yellow Pages Mailer Coupon Sign/Location Newspaper Ad Personal Recommendation Who do we have to thank for telling you about our hospital?Section BreakPatient #1*(Pet name)Species* Dog Cat Breed*Color*Age*Sex*Spayed/Neutered?* Yes No Last Veterinary Exam/Vaccination Date:* MM slash DD slash YYYY Hospital/Clinic/Dr Last Seen:*Do you have records?* Yes No Any major medical issues current or prior?*Do you have a second pet?* Yes No Patient #2*(Pet name)Species* Dog Cat Breed*Age*Color*Sex*Spayed/Neutered?* Yes No Last Veterinary Exam/Vaccination Date:* MM slash DD slash YYYY Hospital/Clinic/Dr Last Seen:*Do you have records?* Yes No Any major medical issues current or prior?*Have your pets had:Any Allergies to vaccinations or medications?*Is your pet/s on any special diet or medication?*What type of heartworm prevention and flea control is your pet currently receiving monthly?*Date of last dose: MM slash DD slash YYYY If a patient is determined to have fleas and/or ticks, treatment will be administered, and owner will be responsible for cost of treatment. We accept the following forms of payment. Which do you prefer? Cash Check Credit Card Care Credit It is our policy that all payments are due at the time of the service with no exceptions. By signing below, you acknowledge that all bills will be paid in full at each visit and you are aware of our policies regarding payment.Signed:*Date* MM slash DD slash YYYY MEDIA RELEASE* I grant Krum Veterinary Hospital the right to use my pet’s story medical condition, video, audio, and or any photos on their website or social media pages (including but not limited to website, Facebook, Twitter, and Google plus). I/we understand that only my pet’s first name will be used. I/we also understand that in the photos of my pet I also may be included or other members of my family. I release Krum Veterinary Hospital of any labiality in the use of these photos. I/we further acknowledge and agree that neither I nor any individual in these videos or photos have ownership interest in any advertising material which utilizes or incorporates the photographic images, video or audio recordings. I DO NOT GRANT KVH TO TAKE PHOTOS OF ME OR MY PET Client Records Upload Drop files here or Select filesMax. file size: 356 MB, Max. files: 5.
