New Client Form

New Client Information

Please return this form promptly, at which time our New Client Coordinator will contact you to follow up. The Appointment Reservation Fee has been credited to your account and will be applied toward your invoice at your pet’s appointment. If the appointment is canceled with a minimum of 1 business day’s notice, we will be happy to refund your fee. If the appointment is rescheduled with a minimum of 1 business day's notice, the Reservation Fee will be applied to the rescheduled appointment. However, if you reschedule more than two times, the current Reservation Fee is nonrefundable, and we will ask you for a new Reservation Fee. If less than 1 business day’s notice is given for cancellation, the reservation fee cannot be refunded. Thank you for respecting our doctors' schedules.

Address

Cell Phone Number*

Spouse or Significant Other Cell Phone Number

Home Phone Number

Primary Email (Required; we send many of our communications by email)*

Pet's Name

What type of pet is this?

If none of the above, please tell us what type of pet you have:

What breed is your pet?

Color

Date of birth (approximate if you do not know, or leave blank for us to determine)

Gender

Our pet is:

Please list any previous illness or surgeries

Please list any known allergies your pet has

List any special diet or medications your pet is on

New Patient Records Release

We need to receive your records before your appointment so that our veterinarians can prepare for your first visit. If you do not have veterinary records yet, please provide us with your paperwork from a shelter, rescue or breeder.

Failure to share your records with us may result in a delay in your appointment.

If you have your records, please provide us with a complete copy (complete medical records from the veterinarian, not just your invoices and/or medical notes from your visits). Please email, fax or drop them by our hospital.

Most veterinary practices will not release records without the owner’s permission for privacy reasons, so please call your veterinarian and ask them to send records for all pets you are transferring to our care to us. They may email or fax them to us at:

Email: supportstaff@centreanimalhospital.com

Name of Previous Veterinarian (please include in case we have follow-up questions for them)

Previous Veterinarian's 10-digit Phone Number

Date

Financial Policy

Thank you for choosing Centre Animal Hospital. Our primary mission is to deliver the best and most comprehensive veterinary care available for your pet. Centre Animal Hospital requires payment in full at the end of your pet’s examination and/or at the time of the discharge.

Payment Options

Cash or check.

Visa®, MasterCard®, or Discover Card

CareCredit® - This a convenient monthly payment plan which will allow you to begin treatment today and pay over time . Care Credit is available for any treatment amount up to your limiti once you have been approved. Care Credit can be used repeatedly once it is paid off for your entire family without having to reapply. Ask us for an application or apply online at carecredit.com.

Pet Insurance

While we work with many pet insurance plans, we recommend Pumpkin Care. Visit pumpkin.care and click on "Create Plan" for a free estimate.

Pet insurance plans require that the owner pay the veterinary invoice at the time of the appointment and then submit invoices and medical records to their pet insurance plan for reimbursement. We are happy to provide you or your insurance company with the pertinent records.

Additional Policies

Centre Animal Hospital charges a fee 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.

If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available to your pet.

By signing below, you agree to the previously listed terms of payment.

Client/Owner Name*

Today's Date

Release of Information for Social Media and Website Use

After an explanation of its intended use, I authorize the staff at Centre Animal Hospital to release photographs, videotape images, or other images to use with any of the following media entities:

Centre Animal Hospital website
Brochures and other print media
Facebook
Instagram
Other forms of social media
Print or online advertising

I understand that this information may be used on print media, on a brochure or on the website of this veterinary practice and/or social media for public education and interaction purposes and agree to its use in that manner.

I, the undersigned, am interested in educating and sharing with the public photos of all pets listed on this form. and authorize this veterinary practice or institution’s faculty, clinicians, employees, students, and/or agents to use such materials for this purpose. I agree not to file any claim for revenue or lawsuit for damages against this veterinary practice with respect to the release of this information.

Your name

Today's Date

Fear Free Questionnaire

Preparing for Your Pet's Visit to Our Hospital

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

Are there things you or your pet did not like during previous veterinary visits?

Anything else you or your pet had problems with in the past?

How would you describe your pet around people or other animals, especially as it relates to the waiting area of our hospital?

What are your pet's favorite treats? (We'd love it if you brought some along!)

What are your pet's favorite toys? (Please feel free to bring along a toy or comfort item.)

Has your pet ever been prescribed any medications to help with a visit to a veterinary hospital?

If you answered "Yes" above, what were the medications and what sort of results did you experience.

A successful Fear Free visit begins at home! It continues during your travel to the hospital.

How and where does your pet travel? Mark all that apply

Does your pet show any reluctance to getting in the carrier or vehicle?

How does your pet behave in the car? Mark all that apply.

Does your pet do any of the following? Mark all that apply

Have you ever used a calming pheromone, either in a spray form or via a plug-in, to help you pet relax at home or during travel?

Please add additional pets here. For each additional pet, share Name/Species/Breed/dob or age if dob unknown/color/gender and whether spayed or neutered/indoor or outdoor pet/past illnesses or surgeries/allergies/foods and medications/ any notes about behavioral concerns that may be helpful. If you do not have enough space, please send additional info via email to:supportstaff@centreanimalhospital.com with your name and the pet's name in the Subject line.