New Client Form

Client Information

Name

Address

Primary Phone*

Primary Phone*

Secondary Contact

Secondary Phone Number

Patient Information

Pet's Name*

Current on Heartworm Prevention*

Current on Flea/Tick Preventative

Any medical concerns or special alerts?

Any known allergies?

Previous Vet Clinic/Hospital name and address

How did you hear about us?*

Please read carefully; a signature is required before examination or treatment will be given.

All fees are due at the time services are rendered. I further understand that I am responsible for all fees associated with my pet’s treatment.

I certify that I am at least eighteen (18) years of age or older and am the owner or authorized agent for the above listed pet. I hereby consent and authorize Vista Hills Animal Hospital and its doctors, employees, and representatives to administer such treatment, diagnostic, surgical and anesthetic procedures as they deem necessary. None of the above will be held liable or responsible in any manner whatever, under any circumstance for the care, treatment or safekeeping of the animal described above, as it is thoroughly understood, I assume all risks.

I hereby certify that I have read and fully understand the above authorization for medical and/or surgical treatment. I also verify that no guarantee or assurance has been made as to the results that may be obtained. Further, I assume financial responsibility for all charges incurred to patient, consent to release of medical information, and authorize direct payment to Vista Hills Animal Hospital.

On occasion, me or my pet’s likeness may be captured on video, photographs or other media. I hereby authorize and grant to Valley Veterinary Care and its affiliates a perpetual, royalty-free license to publish, distribute, use, broadcast, adapt or otherwise use such media for any commercial or non-commercial purpose. I understand I will not be compensated for any such use nor receive prior notice of any such use.

​​​​​​​I consent to receiving communications from Vista Hills Animal Hospital by email, phone, and text messages.

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OWNER/AGENT*