Client Information Form — Veterinary Healing Arts

Subject

Your Name

First Name

Last Name

Spouse/Partner's Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

(###)

###

####

Home Phone (if applicable)

(###)

###

####

Work Phone

(###)

###

####

May we call you at work?

Yes

Driver's License

Employer

Occupation

How did you hear about us?

Primary Veterinarian

Secondary Veterinarian

Friend

Family

Internet

Groomer

Other

If you were referred by a person, please share their name or their organization's name:

It is very important to us that you pet's primary veterianarian know what treatment and medications your pet is receiving from us. Please provide the contact information of the veterinarian that you would like to receive these progress reports.

Veterinarian Name

Clinic Name:

Veterinarian Phone Number:

Veterinarian Email:

Pet Name:

Sex:

Male

Female

Spayed/Neutered

Intact

Species

Canine

Feline

Other

If other, please specify:

Breed:

Color:

Birth Date:

Weight:

Originally Obtained From:

Veterinary Healing Arts, Inc. (VHA) specializes in the treatment of allergies, ears, and skin disease only. If your pet has any other medical or surgical needs, you should consult with your primary care veterinarian. All fees are due upon release of your pet. Any medications, antigens, or other medical supplies mailed to you will be billed separately and in addition to appointment charges. We accept cash, personal checks, MasterCard, Visa, Discover, American Express, as well as Apple Pay and other tap-and-go payments. Should any checks be returned for nonpayment there will be a $30 returned check fee. We are leaders and teachers in the field of veterinary dermatology. Medical files, thus case information, and/or photos may be used in teaching, forms, continuing education, website, veterinary literature, and the like. I authorize the release of case/patient information for such purposes; client confidentiality (names and personal information) will be maintained. I understand that no guarantees can be made as the results obtained from medical treatment. Further, I assume financial responsibility for all charges incurred by the patient.

Due to our busy caseload and long waiting list, we ask that if you must cancel your appointment you do so at least 24 hours beforehand so that we can try to help another client during your reserved time. There will be a cancellation fee should you not provide such notice. Please understand this is to allow all patients who need our services the chance to be seen.

Signature of owner or responsible agent

Date