Owner's Name *

First

Last

Email *

Phone *

Pet's Name *

What brings you in today? *

Does your pet go to the:

If other, please specify:

Is your dog on heartworm prevention?

Yes
No

Are you interested in injectable heartworm prevention as an alternative?

Yes
No

If yes, which brand?

Where did you purchase your heartworm prevention?

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Is your dog on flea/tick prevention? *

Yes
No

If yes, which brand?

Where did you purchase your flea/tick prevention?

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BCVH vaccination & testing recommendations for dogs:

Core vaccines that every dog should receive-

Rabies (per state law)
Distemper (DHPP/DAPPv)

Non-core vaccines that we strongly recommend in our area-

Leptospirosis (annual)
Lyme (annual)

Non-core vaccines based on lifestyle-

Bordetella (kennel cough) for dogs who visit groomers, kennels, day care, or dog parks

Semi-annual & annual testing-

Heartworm/tick borne disease testing: started at 7 months of age and then annual testing for life or if symptomatic for heartworm disease/tick borne diseases including Lyme, Anaplasma, and Ehrlichia.
Bloodwork & urinalysis testing:

BCVH vaccination & testing recommendations for dogs: Core vaccines that every dog should receive- Rabies (per state law) Distemper (DHPP/DAPPv) Non-core vaccines that we strongly recommend in our area- Leptospirosis (annual) Lyme (annual) Non-core vaccines based on lifestyle- Bordetella (kennel cough) for dogs who visit groomers, kennels, day care, or dog parks Semi-annual & annual testing- Heartworm/tick borne disease testing: started at 7 months of age and then annual testing for life or if symptomatic for heartworm disease/tick borne diseases including Lyme, Anaplasma, and Ehrlichia. Bloodwork & urinalysis testing: Required prior to any anesthetic procedure Annual testing recommended for pets of all ages Semi-annual testing for dogs 5 years and older, and those that are on chronic medications. *

I have read and understand BCVH vaccination & testing recommendations.

Is your dog on any medications and if so, what are they, what are the dosages and what is the frequency?

Where do you purchase your dogs medications? *

Do you need a refill of your pets medication? *

Yes
No

If purchasing the medications at an outside pharmacy, would you like BCVH to send in the prescription?

Yes
No

What do you feed your dog and how much?

Any other requests such as nail trim, anal glands, etc.?

Does your pet have pet insurance?

Yes
No

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BCVH Policies

I certify that I am the owner, responsible agent for, or authorized agent of this animal. Decisions regarding the care of my pet shall be made only by me or the coowner/co-agent listed above. Information regarding the care of my pet shall only be released to me or the co-owner/co-agent listed above unless I give written consent to BCVH. *

I have read and understand.

I understand that we require at least 24 hours advanced notice to cancel or reschedule an existing appointment. If less than 24 hours notice is received, our hospital policy is to collect a $100 deposit to reschedule and hold that next time slot. If canceling or rescheduling a sedated and/or surgical appointment, at least 48 hours of advanced notice is required due to the specific time allotments associated with these appointments. If notice is received less than 48 hours in advance, a $100 deposit will be required to reschedule and hold that new sedated/surgical time slot. In both cases, that deposit collected will be used towards the balance of that rescheduled visit although, it will be non-refundable in the case that another appointment is missed or cancelled within the policy time frame. We understand there may be times when unforeseen circumstances occur but by providing us adequate notice, we can accommodate other patients in need of care. *

I have read and understand.

* All fees are due at the time services are rendered * We accept Visa, MasterCard, Discover, and Care Credit credit cards as well as cash and personal checks with proper identification. *

I have read and understand.

I understand that I am financially responsible for any services or products provided and that payment is due in full at the time services are rendered for today's visit along with all future visits. Balances left unpaid, will accrue a 1.5% finance charge per month. I agree to be responsible for paying a $25.00 fee if my check is returned for any reason. I agree to pay a 33.3 % attorney fee if my balance (including any monthly finance charges) is turned over for collection. *

I have read and understand.

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