New Client Information And Financial Agreement | High Prairie Veterinary Services

406-525-3878 HighPrairieVetOffice@gmail.com

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New Client Info & Financial Agreement

Please complete the form below.

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New Client Info & Financial Agreement Form

Name *

First

Last

Cell Phone *

Home Phone

Physical Address *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (if different from above)

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Reminders

Voice
Mail
Email
Text

Pet Information

Pet Name *

Species *

Breed *

Color *

DOB/Age *

Weight *

Sex *

Male
Male Neutered
Female
Female Spayed

Pet Questionnaire

Parvo/Distemper

Date of last vaccine

Feline Combo

Date of last vaccine

Rabies

Date of last vaccine

Bordetella

Date of last vaccine

Fecal Exam

Date of last exam

Heartworm Exam

Date of last exam

Does your pet show sign of illness today? *

Yes
No

If yes, what signs *

Is your pet currently taking any medications? *

Yes
No

If yes, what signs *

Please list previous surgeries:

Has your pet had any previous reactions to anesthesia? *

Yes
No

If yes, explain *

Any behavior concerns? (i.e., Biting, timidness, special handling)

Treatment Authorization

Please check off each statement below

I verify I am the owner (or authorized agent for the owner) of the above-named pet. *

I verify I am the owner

I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that clinic personnel will be employed in the procedure(s) as directed by the veterinarian. High Prairie Veterinary Service (HPVS) will use all reasonable precautions against injury, death, or escape of my pet. *

I authorize the use of anesthesia and other medication

I accept the risk inherent in any anesthesia or surgery and release HPVS of any liability associated with the procedure. I further understandthat there may be additional, deemed necessary, treatment or expenses upon further examination and commencement of my pet’s treatment plan. If my pet has fleas, ticks, mites, or internal parasites, I understand that I will be charged with the cost of removing them. *

I accept the risk

Payment is due at the time of service. If accounts are not paid within 30 days, the account will incur a 10% interest charge automatically each month. If payment plans are needed, we work with Care Credit and Vet Billing. Please discuss these options prior to your appointment. *

I understand

I understand that should I default on payment of my account and collection agency services are required, all costs of collection up to 40% of the balance, including attorney/court costs will be added to the balance of my account. *

I understand

I understand thatif I am unable to pay for services or products in full at time of service, I must make prior arrangements to settle my account. Payment is due at time of service. *

I understand

Signature of Owner/Agent *

Clear Signature

Date *

Payment is due at time of service and this form must be complete.

We proudly serve the pets of Wolf Point and beyond.

Our philosophy is to provide excellent customer service and first rate pet care. We strive to create a relaxing-friendly environment for you and your pet. Our clinic is comfortable, pet-friendly, and calm.

CONTACT US!

Our veterinarians are highly trained in the treatment of any health condition. We’re a full-service mixed animal vet clinic with amenities designed to help you and your pet feel relaxed and at home in the company of our welcoming staff.

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Phone



email

HighPrairieVetOffice@gmail.com

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address

420 Cascade Street
6182 Hwy 13 (mailing)
Wolf Point, MT 59201

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HOUR OF OPERATIONS

Monday – Thursday: 8am – 6pm
Friday: 8am – 5pm
Saturday – Sunday: Closed

We Can't Wait to Meet You!

Ready to schedule your next appointment? Visit out our online appointment request form by clicking below.

We are passionate about working together with you in the best interest of your pet.

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HAVE A QUESTION?

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please contact us if you have any questions or suggestions.

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