New Client Form in Riverview, FL | Brandon Lakes Animal Hospital

Client Name*

First Last

Date*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary phone*

Secondary phone

Cell provider

Privacy Disclaimer: This text message program is provided to clients to notify clients of prescription refills and to follow up after appointments. Your information will not be sold, distributed, or in any other way shared with entities or affiliates outside of Brandon Lakes Animal Hospital.*

I authorize BLAH to send text messages.
l decline to receive text messages at this time.

Employer

Phone

Occasionally we will communicate via email - Please provide a valid email address below.*

Emergency Contact

Phone

Owner signature*

Preferred Contact Method (please check your preferred method to be contacted regarding your pet, this includes status updates and test results from your pet :S recent visit):*

EMAIL
PHONE

PET INFORMATION

Pet's Name*

Date of Birth or approximate age*

*

Dog
Cat

Breed*

Color*

Sex:*

Male
Female

Spay/Neuter*

Yes
No

Current Medications

Current Medical Problems

We at Brandon Lakes Animal Hospital sincerely appreciate referrals. Please inform our receptionist of who referred you and your pet to us.

RECORDS RELEASE

In accordance with the Florida State veterinary law regarding the confidentiality of patient medical records and treatment, a written authorization or other form of waiver executed by the client is required in order for us to provide a copy of your pet's medical records. By signing below you certify that you are the owner and/or agent and have the authorization to make medical and legal decisions for animals listed on your account. You hereby authorize Brandon Lakes Animal Hospital to release your animal's medical records to the requested person or veterinary facility. By signing this document, I herby release Brandon Lakes Animal Hospital and DVM's from any liabilities regarding release of records.

Signature*

Date*

I authorize Brandon Lakes Animal Hospital to take and/or post pictures of my pet.*

Yes
No

ALL FEES ARE DUE UPON PATIENT'S RELEASE

We will provide a written estimate offees before any treatment is administered. The actual cost of treatment may vary depending on factors not evident at the time of original examination. A deposit is REQUIRED if animal is hospitalized for treatment. We DO NOT ACCEPT checks as payment from new clients. We accept Cash, Credit Cards (MasterCard, Visa, and American Express) or Debit Cards. The cardholderMUST be present at the time of payment.

PAYMENT POLICY

Payment is expected at the time of service. If your pet is to stay with us in the hospital we will collect the full estimated treatment plan charges at the time we admit your animal, any additional services are due when you pick, Ufl your pet from the hospital. If a credit is on the account you may elect to have the monies returned to you or left on the account for future use. We do not make payment arrangements; we do however offer a variety of payment options. We accept the following forms of payment. We apologize but we are not able to accept checks as a form ofpayment from new clients.

Cash
Debit Card
Visa
MasterCard
American Express
Care Credit
WE ONLY ACCEPT CHECKS from long-standing clients (over 1 year) in a good financial standing with us.

Please sign to acknowledge that you have read & understand our payment policy*

Date*

Comments

This field is for validation purposes and should be left unchanged.