Company

This field is for validation purposes and should be left unchanged.

Name*

First Last

Phone*

Physical Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address (if different from above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Reminders

Voice
Mail
Email
Text

Pet Information

Pet Name*

Species*

Breed*

Color*

DOB/Age*

Weight*

Sex*

Male
Male Neutered
Female
Female Spayed

In-Patient Pet Questionnaire

Parvo/Distemper

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

Is your pet currently taking any medications?*

Yes
No

Please list previous surgeries

Has your pet had any previous reactions to anesthesia?*

Yes
No

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

Belongings left with your pet today

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

New Client Information & Financial Agreement

Pet Information

In-Patient Pet Questionnaire

Treatment Authorization

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