Primary Owner Name(Required)

First Last

Secondary Owner Name

First Last

Legally, the primary owner must be over 18 and able to make financial/medical decisions. Is the secondary owner over 18 and able to make financial/medical decisions?(Required)

Yes

Relationship of secondary owner to primary owner?(Required)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Contact Number(Required)

Secondary Contact Number

Home Phone

Work Phone

Email(Required)

How did you hear about our clinic?

Neighborhood

Internet/Google

Social Media

Personal Referral

Clinic Referral

Other

Who referred you?

Previous Veterinary Clinic

May we use photos of your pets and family on our website and social media?(Required)

Yes

(We do not use any identifying information beyond your pet’s name.)

By signing this form, you agree that you are over 18 and bound by our Client Responsibility and Client Information Terms (found on the back side of this page.)

Date(Required)

Client E-Signature(Required)

Pet #1 Information

Name(Required)

Species and Breed(Required)

Pet's Age or Date of Birth(Required)

Color(Required)

Sex(Required)

Male

Female

Spayed / Neutered?(Required)

Yes

Pet #2 Information

Name

Species and Breed

Pet's Age or Date of Birth

Color

Sex

Male

Female

Spayed / Neutered?

Yes

Pet #3 Information

Name

Species and Breed

Pet's Age or Date of Birth

Color

Sex

Male

Female

Spayed / Neutered?

Yes

Client Responsibility

All persons under 18 years of age must be accompanied by a responsible party prepared to make financial and medical decisions. We do not grant credit to our clients and expect full payment at the time services are rendered. If your pet is treated and hospitalized, you may be asked to pay 50% of estimated cost at the time of hospitalization. You also agree to pay your bill in full at the time of discharge. In the event that you fail to fully pay your bill on receipt, you agree to pay us a monthly service charge of $2.00 per month and 1.5% of your total unpaid bill outstanding as of the date of billing. Failure to make timely monthly payments will require us to use collection remedies and you agree to pay us for all costs of collection including attorney fees.

Our hospital is a healing environment and a successful veterinary client patient relationship requires mutual respect and trust. We pride ourselves on respectful, compassionate care for clients and patients, and expect that our clients will treat our staff with the same respect and compassion. Abusive language and behavior towards our staff is not tolerated and will result in the severance of our professional relationship.

Client Information

We will never sell or distribute your personal information. To provide you with comprehensive services (for example, to notify you that your pet’s vaccines are expiring, to operate our online pharmacy, and to facilitate two-way texting) we utilize integrated third party services. Your information may be used by those services to send emails, text messages, or postcards, provide online pharmacy access, and to give you access to your pet’s records via an online portal. Your portal allows you to check your pet’s vaccination status, submit refill requests, book appointments online and more. It also allows you to select the ways you would like to receive reminders, or opt out of receiving communications from our clinic. You are automatically opted in to postcards, text messages, and emails.

If you have any questions about the way your information will be used, or need assistance setting your preferences, please let us know!

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New Client Form

Pet #1 Information

Pet #2 Information

Pet #3 Information

Client Responsibility

Client Information

Expert Veterinary Care in Lake Elmo, MN