"*" indicates required fields

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

Client Information

First Name*

Last Name*

Phone*

Email*

Preferred method of contact*

Phone Call

Text Message

Address*

Street Address

Address Line 2

City

State

ZIP Code

Co-Owner's Name

Co-Owner's Phone

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.*

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. For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier.

Photo Consent

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

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 date.

No Show policy outlined:: 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.

Pet Information

Pet's Name*

Species*

Cat

Dog

DOB / Age*

Breed*

Sex*

Male

Neutered Male

Female

Spayed Female

Vaccinations were last given by (clinic name):*

Date vaccines last given*

If under a different person’s name, please list that name here.

Color/Markings*

Allergies or long term medical problems?*

Pet Pre-Visit Questionnaire

How would you describe your pet's reaction to going to the veterinary hospital?*

Eager and excited

Anxious

Calm but reluctant

Totally resistant

Are there any things that you or your pet did not like during past veterinary visits?*

Entering the clinic

Waiting in the lobby

Getting weighed

Going into the exam room

Being on the table

Being handled by staff

Having temp taken

Being away from owner

Does your pet prefer:*

Female Veterinarian

Male Veterinarian

No Preference

What are your pet's favorite treats or toy?*

Can bring the treats or toy

Does your pet show any reluctance to get into the carrier or car?*

Yes

How and where does your pet travel in the car?*

Carrier

Seatbelt

Loose

How does your pet behave in the car?*

Happy

Barking

Whining

Restless

Panting

Trembling

Hiding

Any nausea, drooling or vomiting, with car travel?*

Yes

Would you like to add a second pet?*

Yes

Second Pet Information