Client/Patient Update Form – Quinebaug Valley Veterinary Hospital

About You

Name *

First

Last

Spouse/Co-Owner's Name

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Primary Phone *

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. *

Please sign

Date *