860-774-7650
Contact@QVVH.com
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Client/Patient Update Form
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About You
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*
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*
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*
Secondary Phone
Spouse/Co-Owner's Phone
About Your Pet(s)
Pet's Name
*
Species
*
Dog
Cat
Other
If other, please specify
*
Breed
*
Color
*
Sex
*
Male
Male (neutered)
Female
Female (spayed)
Age/Date of Birth
*
Add another pet?
*
Yes
No
Pet's Name
*
Species
*
Dog
Cat
Other
If other, please specify
*
Breed
*
Color
*
Sex
*
Male
Male (neutered)
Female
Female (spayed)
Age/Date of Birth
*
Add another pet?
*
Yes
No
Pet's Name
*
Species
*
Dog
Cat
Other
If other, please specify
*
Breed
*
Color
*
Sex
*
Male
Male (neutered)
Female
Female (spayed)
Age/Date of Birth
*
Add another pet?
*
Yes
No
Pet's Name
*
Species
*
Dog
Cat
Other
If other, please specify
*
Breed
*
Color
*
Sex
*
Male
Male (neutered)
Female
Female (spayed)
Age/Date of Birth
*
Add another pet?
*
Yes
No
Pet's Name
*
Species
*
Dog
Cat
Other
If other, please specify
*
Breed
*
Color
*
Sex
*
Male
Male (neutered)
Female
Female (spayed)
Age/Date of Birth
*
Have your pets been seen by another clinic since their last visit with us?
*
Yes
No
Clinic's Name
*
Clinic's Phone
*
Reason for Visit
*
Payment Policy
Our office does not bill. Payment is due on the day of service. We will gladly prepare a written estimate if you desire. Please ask our doctor during your appointment. Occasionally, a deposit may be required for certain procedures. We accept the following forms of payment: cash, credit/debit (including Visa, Mastercard, Discover, and American Express).
*
I have read and understand
Social Media Release
I grant permission for Quinebaug Valley Veterinary Hospital to use photos of my pet for the purpose of social media posting (Facebook, Twitter, Youtube, and other sites).
*
Use image only
Use image and my pet's first name
I do not grant permission
Treatment/Payment Authorization
I understand every effort will be made to achieve a successful outcome, and provisions will be made for safe in-hospital care and handling. I certify that I am 18 years of age or older and assume responsibility for all charges incurred. I understand that charges are due at the time services are completed unless prior arrangements have been made. I agree that should my account become delinquent; I will be responsible for all collection costs, including but not limited to the outstanding balance, interest, attorney fees, court costs, and collection agency fees.
*
I have read and understand
I hereby authorize Quinebaug Valley Veterinary Hospital to treat my pet(s) and furthermore understand that unforeseeable adverse reactions to treatments are always possible and authorize treatment necessary should any reactions occur.
*
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