St. Petersburg's Best Vet Clinic | Northeast Animal Hospital

Location(Required)

CLIENT / OWNER INFORMATION

Name(Required)

First Last

Address 1(Required)

Address 2

City(Required)

State(Required)

Zip(Required)

Main Phone(Required)

Alternate Phone

Email(Required)

Driver's License #(Required)

For identification and payment purposes, a copy of any authorized individual’s drivers license is required.

Payment Method(Required)

SPOUSE / CO-OWNER INFORMATION

Name

Main Phone

Alternate Phone

HOW DID YOU HEAR ABOUT US?

How did you hear about us?

Please check all that apply.

Individual(s) (Please specify below)

Drove by/Saw street sign

Our sister practice

Google

Yelp

Facebook

Advertisement (Please specify source below)

Other (Please specify below)

Please specify

DOCTOR REFERRAL

If you have been referred to us by another veterinarian, please provide their information below.

Doctor's Name

Hospital Name

State

Phone

PET INFORMATION 1

Name

Type of Pet

Other

Breed

Color

Date of Birth

Sex

Spayed / Neutered?

Please give a brief history of your pet

PET INFORMATION 2

Name

Type of Pet

Other

Breed

Color

Date of Birth

Sex

Spayed / Neutered?

Please give a brief history of your pet

PET INFORMATION 3

Name

Type of Pet

Other

Breed

Color

Date of Birth

Sex

Spayed / Neutered?

Please give a brief history of your pet

PHOTO/VIDEO RELEASE

We would like to use your pet(s) photos and/or videos for fun things like Facebook, advertising, client education, etc.

Photo/Video Release Consent(Required)

I hereby give my permission and grant to you, Northeast Animal Hospital and/or Downtown St. Pete Vet Clinic, the right to use my pet's name and/or likeness, and the right to photograph and/or video his/her likeness. In addition, I hereby consent to the use of his/her name, likeness, photo(s)/video(s), and any reproduction thereof in or in connection with production, exhibition, distribution, and advertising on social media, print, display, or other media. I understand that I will not receive any monetary payment, now or in the future, for my participation within the use of these photos and/or videos.

I do not wish you to photograph or video my pet/pets, or to use his/her name or likeness in any production, exhibition, distribution, or advertising.

NO SHOW POLICY

Your scheduled appointment time is reserved just for you and your pet. We try not to overbook appointment times in order to provide excellent veterinary care and to be sure we have sufficient time to examine your pet and to discuss your pet’s condition and treatment options in detail with you.

We will make every effort to accommodate your scheduling needs. In return, we ask that you help us by keeping your scheduled appointments, arriving on time and notifying us a minimum of twenty-four (24) hours in advance if you are unable to do so. When we receive advanced notice of cancellation, we are able to accommodate other patients needing our care. If you miss your appointment the following will apply:

First and Second missed appointment: Our staff will call to ensure you and your pet are all right and to reschedule your appointment.
Third missed appointment: You will receive a letter stating this is your third missed appointment and that you have been charged a missed appointment fee ($25.00).

ACKNOWLEDGEMENT

I hereby state that I am the owner, and/or the authorized agent for the owner, and have permission to make all decisions pertaining to the above pet(s). PROFESSIONAL FEES ARE DUE AT THE TIME OF SERVICES RENDERED. We will gladly prepare a written estimate if you desire. Please ask the receptionist, technician, or doctor.

Signer Name(Required)

Comments

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

New Client Form

CLIENT / OWNER INFORMATION

SPOUSE / CO-OWNER INFORMATION

HOW DID YOU HEAR ABOUT US?

DOCTOR REFERRAL

PET INFORMATION 1

PET INFORMATION 2

PET INFORMATION 3

PHOTO/VIDEO RELEASE

NO SHOW POLICY

ACKNOWLEDGEMENT