New Client Form Today's Date(Required) MM slash DD slash YYYY Have you ever brought a pet to Hickory Veterinary Hospital before?(Required) Yes No Client InformationName(Required) First Last Email(Required) Primary Phone(Required)Secondary PhoneMy secondary contact number is:(Required) Home Number Cell Number Work Number Someone else’s number Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code How would you prefer to be contacted? Phone (main number) Text (main number) Email Phone (secondary number) Text (secondary number) Is there an additional person you would like listed on this account?(Required) Yes No Additional Person's Name and Phone NumberIn case of an emergency, is there anyone else (besides above listed contacts) who should be listed on your account and who has ongoing permission to make medical decisions for your pets?(Required) Yes No Emergency Contact's Name and Phone NumberHow did you hear about us? Facebook Google Saw our hospital (location) Referral Patient InformationPet's Name(Required)Species Dog Cat Date of Birth/Age of Your Pet MM slash DD slash YYYY Breed and Color (if your cat is not a known breed, do they have long, medium, or short hair)(Required)Sex(Required) Male Neutered Male Female Spayed Female Is your pet microchipped Yes No Primary reason for your visit to Hickory Veterinary Hospital?(Required)Do you already have a scheduled appointment?(Required) Yes No I scheduled an appointment through your website Previous Veterinarian/Veterinary Hospital(s)(Required)If none, please let us know that!Would you like to add another pet?(Required) Yes No Client Policies and Procedures: We want you to be aware of and understand the following policies and procedures for all clients.We must receive your pet's medical history and records from your previous veterinarian no less than 7 days prior to your appointment; otherwise, you will need to reschedule your appointment. *(Required) I have read and understandWe love social media! Do we have your permission to post pictures and/or videos of your pet(s), you and your pets(s), and/or your pet(s) and our team on Facebook, Instagram, Twitter, our website, and any other marketing and/or social media outlets we may choose to use?(Required) Yes No This field is hidden when viewing the formWe require a deposit for each visit in the amount of the exam fee. We also require a 48 hours notice of desired modifications or cancellations for appointments in order to request a refund. After 48 hours, the deposit is non-refundable I have read and understandHickory Veterinary Hospital uses email, text, and our own hospital app for communications regarding our patients' reminders for health care needs. Do we have your permission to contact you via email, text and/or our app regarding these reminders?(Required) Yes No Financial Policy: We do not bill. All fees are due at the time that services are rendered. we accept many different payment options, including all major credit cards (VISA, MasterCard, Discover, American Express), cash, check, CareCredit, and Scratchpay.(Required) I have read and accept the financial policy.Code of Conduct: Hickory Veterinary Hospital team members, clients, and patients must be treated with respect at all times. Pets must be leashed or in a carrier while in the parking lot, lobby, hallways, and any other area of the clinic where they may encounter other people and pets. Any concerns regarding your pet’s care or our client service will be addressed respectfully with a member of the management team. Please understand that emergencies and urgent visits may unexpectedly affect our schedule. We ask for your understanding as we provide life-saving care to these pets, and remember that we will do the same for your pet if/when the need arises. Please allow 72-business-hour notice for filling medication and food orders. The following behaviors will not be tolerated: verbal abuse, malicious or harmful statements about others, profanity or disrespect, any form of harassment or bullying, discriminatory comments or actions, intimidation tactics, and/or making threats, failure to comply with the requests of our staff, including leashing/restraining your pet, etc. We reserve the right to discontinue services immediately if you are in violation of this code of conduct.(Required) I have read and accept the code of conduct.Signature Δ
