New Client Information Form

Photo/Video, Social Media Authorization

With your permission, we occasionally post images and videos of our patients, patients with our staff, and patients with their people on our social media sites and/or our website.

We don't mind at all, if you would prefer not to have any photos or videos shared, but we would like a photo for our records.
Authorization to use photos related to veterinary house calls taken at my residence:

I approve the use of all photos of my pet, myself and my pet, and my pet with AHVS staff that are taken during the house calls, for display on the AHVS website and/or social sites. I approve the use of photos of my pet(s) and/or pet(s) and AHVS veterinary staff only (no images of the client or other people in the home will be taken), for display on the AHVS website and/or social sites I approve a photo to be used for medical records only.

General Safety

We strive to provide the lowest stress veterinary visit and examination possible, using the least amount of restraint (none if possible).

You are welcome to be near and observe the examination, but to ensure our staff's safety, the safety of your pet and yourself, after the examination begins, please do not attempt to hold, restrain or put your hands near the face or mouth of your pet.
I agree that I will not hold, restrain or put my hands near the face or mouth of my pet once the examination begins. *

I agree

Emergency Changes to Appointments

Occasionally, when our appointments are full, another sick patient may need help.

If your scheduled appointment is a wellness appointment or not urgent, we may want to ask you if you would be willing to move your appointment to another day.

We would only contact you if your scheduled visit was for a wellness visit (annual exam) or other non-urgent appointment.
May we contact you to move the time or date of your wellness or non-urgent appointment to accommodate a seriously ill pet or an urgent euthanasia? *

Yes, please call to see if I can move No, I usually cannot change my schedule

Payment

Payment is required at the time of service or when your invoice or statement is received. All forms of payment are accepted. Cash or checks are preferred.

Statements for clients with a balance on their account will be e-mailed or mailed at least twice monthly. Past due accounts will be assessed a minimum $2.00 or 2.0% financing fee (whichever is higher) for accounts greater than 30 days past due.

Accounts greater than 90 days past due are sent to collections.
I understand that payment is due at the time of service or upon receipt of an invoice or statement, and I agree to meet the payment terms. *

I agree

Are you completing this form on a phone, tablet or other touch enabled device?

No Yes
By typing my name below, I confirm that the information in this form is true and I agree to all terms set forth in this document. *
By signing my name below, I confirm that the information in this form is true and I agree to all terms set forth in this document. *

Please use your finger or stylus to sign on the line above. Clear
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New Patient Information
Pet #1 Name:
Species

Feline Canine
Breed
Color(s)
Approximate Age:
Please enter date of birth if known.
Male or Female

Male-Neutered Male-Intact Female-Spayed Female-Intact
Approximate Weight
Please indicate if pounds or kg.
Name of Previous Veterinary Practice
Previous Vet Phone Number

- Area Code Phone Number
City and State of Previous Vet:
Month/Year of Last Exam
Please attach a favorite photo - or photos - of your pet (optional):

Upload a File

Cancel of
Please attach any records you may have (optional):

Upload a File

Cancel of
Do you have a second pet to add?

Yes No

Pet #2 Name:
Species

Feline Canine
Breed
Color(s)
Approximate Age:
Please indicate years/months if known.
Male or Female

Male-Neutered Male-Intact Female-Spayed Female-Intact
Approximate Weight
Please indicate if pounds or kg.
Name of Previous Veterinary Practice
If different from previous pet.
Previous Vet Phone Number

- Area Code Phone Number
City and State of Previous Vet
Month/Year of Last Exam:
Please attach a favorite photo - or photos - of your pet (optional):

Upload a File

Cancel of
Please attach any records you may have (optional):

Upload a File

Cancel of
Do you have a third pet to add?

Yes No

Pet #3 Name:
Species

Feline Canine
Breed
Color(s)
Approximate Age:
Please indicate years/months if known.
Male or Female

Male-Neutered Male-Intact Female-Spayed Female-Intact
Approximate Weight
Please indicate if pounds or kg.
Name of Previous Veterinary Practice
If different from previous pet
Previous Vet Phone Number

- Area Code Phone Number
City and State of Previous Vet
Month/year of Last Exam:
Please attach a favorite photo - or photos - of your pet (optional):

Upload a File

Cancel of
Please attach any records you may have (optional):

Upload a File

Cancel of
Do you have a fourth pet to add?

Yes No

Pet #4 Name:
Species

Feline Canine
Breed
Color(s)
Approximate Age:
Please indicate years/months if known.
Male or Female

Male-Neutered Male-Intact Female-Spayed Female-Intact
Approximate Weight
Please indicate if pounds or kg.
Name of Previous Veterinary Practice
If different from previous pet.
Previous Vet Phone Number

- Area Code Phone Number
City and State of Previous Vet:
Month/Year of Last Exam:
Please attach a favorite photo - or photos - of your pet (optional):

Upload a File

Cancel of
Please attach any records you may have (optional):

Upload a File

Cancel of
Do you have a fifth pet to add?

Yes No

Pet #5 Name:
Species

Feline Canine
Breed:
Color(s)
Approximate Age:
Please indicate years/months if known.
Male or Female

Male-Neutered Male-Intact Female-Spayed Female-Intact
Approximate Weight
Please indicate if pounds or kg.
Name of Previous Veterinary Practice
If different from previous pet.
Previous Vet Phone Number

- Area Code Phone Number
City and State of Previous Vet:
Month/Year of Last Exam:
Please attach a favorite photo - or photos - of your pet (optional):

Upload a File

Cancel of
Please attach any records you may have (optional):

Upload a File

Cancel of
Do you have more pets to add?

Yes No
If you answered yes, a member of our staff will e-mail you a link to an "Additional Pets Form." so you may submit the information about the rest of your furry family!
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At Home Veterinary Services