New Pet Registration Form

We thank you for the opportunity to provide veterinary care for your pet.

Please take a few moments to fill out this form as complete as possible.

Owner/Client Name(Required)

Email(Required)

Primary Phone(Required)

Mailing Address(Required)

Street Address

City

State / Province / Region

ZIP / Postal Code

Preferred method of contact(Required)

Text Message

Phone Call

Spouse’s/Co-Owner’s Name

Spouse’s/Co-Owner’s Contact

TREATMENT CONSENT

I hereby authorize the veterinarian to examine, prescribe for or treat the below-described pet(s) to the best of their abilities. I assume responsibility for all charges incurred in the care of this animal.

After hours emergency care is referred to either K-State University Teaching Hospital (785)532-5690 or Veterinary Emergency & Specialty Hospital of Wichita (316)262-5321.

I give permission to release the following information regarding my pet(s) to inquiring veterinary, boarding, rescues, or grooming facilities.(Required)

Medical Info

Vaccine Info

Do Not Release Info

FINANCIAL POLICY

Payment methods: Cash, Check, Visa, MasterCard, Discover, Amex, Care Credit & Scratch Pay.

(Some conditions apply and subject to credit approval)

We require payment in full at the time of service.

If there is an outstanding balance, we charge 18% interest. If an account is turned over to a collection agency there is a one-time collection fee of $35.00 that is added to the account prior to turnover. We also charge $15.00 for returned checks.

PHOTO CONSENT

Do we have your permission to share your pet(s)’ photos and/or videos of you and/or your pet.(Required)

Yes

APPOINTMENT POLICIES

Confirming Appointments: As a courtesy, you will be contacted prior to your appointment by text, email, or phone. If you have not confirmed your appointment 24 hours prior, we reserve the right to reschedule you.
Cancellation of an Appointment: To be respectful of the needs of other patients, please call us at least 24 hours prior to your appointment if you need to cancel.

Late Arrival: If you arrive more than 10 minutes after your pet’s appointment start time, you will be asked to reschedule for a later time and/or date.

No Show policy: A no-show appointment occurs when a patient is not present at the time of their scheduled appointment and has not provided adequate notification. Adequate notification is defined as at least a 24-hour notice. After a client has two no-show appointments, that client and any persons who is either a guarantor for, or guarantee of, the account in question may be asked to pay up front for the exam fee. If adequate notice is not given the exam fee will be kept and the client will be charged a no-show appointment fee equal to the prepaid exam fee and will not be refundable.